I provide consent for communication of my medical records to the following individuals or organizations, in addition to the above listed:
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND
HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE
REVIEW THIS DOCUMENT CAREFULLY.
Alta Rehab is dedicated to maintaining the privacy of individually identifiable health information as protected by law, including the Health Insurance Portability and Accountability Act (HIPPA). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. This information is referred to as protected health information or PHI. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our organization concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
This notice contains the following required information:
The terms of this notice apply to all records containing your PHI that are created or retained by our organization. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our organization has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our organization will post a copy of our current Privacy Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
The following categories describe the different ways in which we may use and disclose your PHI.
1. Treatment. Our organization may use your PHI to treat you. For example, we may ask you to have evaluations and we may use the results to help us develop an individual plan for services. Many of the people who work for our organization including, but not limited to, our therapists, educators, case managers, doctors, and nurses may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may also disclose your PHI to your primary care physician or other outside health care providers for purposes related to your treatment. Finally, we may disclose your PHI to family members or others who may assist in your care.
2. Payment. Our organization may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer, including Medicaid, to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to Medicaid and other payers or providers to coordinate and assist their billing efforts.
3. Health Care Operations. Our organization may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our organization. We may disclose your PHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our organization may use and disclose your PHI to contact you and remind you of an appointment.
5. Treatment Options.Our organization may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our organization may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our organization may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a caregiver take an individual to the doctor's office for examination for seizures that occurred while at our organization. We may give the caregiver a copy of a case note for the physician documenting the seizure(s). In this example, the caregiver may have access to this individual's medical information.
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
1. Public Health Risks. Our organization may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
2. Health Oversight Activities. Our organization may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our organization may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
5. Deceased Persons. Our organization may release PHI to a medical examiner or coroner to identify cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
6. Research. Our organization may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when Internal or Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;
(ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
7. Serious Threats to Health or Safety. Our organization may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances we will only make disclosures to a person or organization able to help prevent the threat.
8. National Security. Our organization may disclose your PHI to federal officials for intelligence and national security activities authorized by law.
9. Workers' Compensation. Our organization may release your PHI for workers' compensation and similar programs.
You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to the Program Director or Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members, guardians, and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Program Director or Privacy Officer. Your request must describe in a clear and concise fashion:
3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Program Director or Privacy Officer in order to inspect and/or obtain a copy of your PHI. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our organization may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to the Program Director or Privacy Officer. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the organization; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our persons served have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our organization has made of your PHI, e.g., for non-treatment, nonpayment or non operations purposes. Use of your PHI as part of the routine care in our organization is not required to be documented. For example, the therapist sharing information with the educator; the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. Also, we are not required to document disclosures made pursuant to an authorization signed by you. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our organization may charge you for additional lists within the same 12- month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact any Program Director or the Privacy Officer.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, contact the any Program Director or the Privacy Officer. We urge you to file your complaint with us first and give us the opportunity to address your concerns. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, however, that we are required to retain records of your care.
1801 East 2nd Street
Scotch Plains, NJ 07076
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