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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This notice is effective as of November 1, 2003
USES AND DISCLOSURE OF HEALTH INFORMATION
TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Seniors Inc. uses and discloses your protected health information for
treatment, payment and health care operations. Some examples of when
our office may use or disclose your health care information for these
purposes include:
- Providing your diagnosis or other information about your health
to your insurance provider or our billing service to obtain payment
for the health care services we provide;
- Reviewing information as part of our quality improvement program.
OTHER USES AND DISCLOSURES
Seniors Inc. may also use or disclose your protected health information,
in compliance with guidelines outlined by law, for the following purposes:
- Providing you with information related to your health;
- Contacting you regarding appointments, information about treatment
alternatives, or other health related services;
- Incidental uses or disclosures (e.g., listing your name on a sign-in
sheet, etc.);
- Compliance with all laws (including reports of suspected abuse,
neglect or violence);
- Providing certain specified information to law enforcement or correctional
institutions;
- Providing information to a coroner, medical examiner, funeral director,
or organ procurement organization;
- Public health activities when requested by a public health authority
or the FDA.
- Responding to health oversight agencies;
- Responding to court or administrative tribunal orders, subpoenas,
discovery requests or other lawful process;
- Research activities;
- When necessary to avert a serious threat to health or safety;
- Military affairs, veterans affairs, national security, intelligence,
Department of State, or presidential protective service activities;
- Providing information regarding your location, general condition
or death to public or private disaster relief agencies; or
- Informing a family member, other relative, or close personal friend
when:
- Information is relevant to the individual’s involvement
with your care;
- Notification of your location, general condition or death;
- To assist in your heath care (e.g., pick-up prescriptions or
other documents, note follow-up care instructions, etc.).
AUTHORIZATION FOR OTHER USES
Seniors Inc. will make other uses and disclosure of your protected
health information only after obtaining your written authorization.
If you authorize a use not contained in this notice, you may revoke
your authorization at any time by notifying us in writing that you wish
to revoke your authorization.
YOUR RIGHTS REGARDING THE PRIVACY OF YOUR HEALTH INFORMATION
Subject to limitations outlined by law, you have certain rights related
to use and disclosure of your protected health information, including
the right to:
- Request restrictions on certain uses and disclosures. However,
Seniors Inc. is not obligated to agree to requested restrictions.
- Receive confidential communications of protected health information.
- Inspect and copy your protected health information with some limited
exceptions;
- Amend your health information;
- Receive an accounting of disclosures of your health information;
- Obtain a copy of this notice.
SENIORS INC. DUTIES REGARDING THE PRIVACY OF
YOUR HEALTH INFORMATION
Subject to limitations outlined by law, Seniors Inc. has certain
duties related to your protected health information, including:
- Seniors Inc. is required by law to maintain the privacy of protected
health information and to provide individuals with notice of our legal
duties and privacy practices with respect to protected health information.
- Seniors Inc. is required to abide by the terms of the privacy
notice that is currently in effect.
- Seniors Inc. reserves the right to change a privacy practice described
in this notice and to make such change effective for all protected
health information. Revised notice will be posted in our office and
available upon request.
CONCERNS
If you believe your privacy rights have been violated, you may make
a complaint by contacting the Seniors Inc. Human Resources Coordinator,
5840 E. Evans Ave, Denver, CO, 80222, 303-300-6900 or the Secretary
for the Department of Health and Human Services. No individual will
be retaliated against for filing a complaint.
ACKNOWLEDGEMENT
I acknowledge that I have received a copy of this notice regarding
the use and disclosure of my health information.
_______________________________________ _______________________
Signature Date
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