"Notice of Privacy Practices" - Florida

Notice of Privacy Practices is a legal document that was released by the Florida Department of Elder Affairs - a government authority operating within Florida.

Form Details:

  • Released on September 22, 2013;
  • The latest edition currently provided by the Florida Department of Elder Affairs;
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Notice of Privacy Practices
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
Effective Date: September 22, 2013
effective. We may also use your protected health
Department of Elder Affairs’ Duties
information to: contact you as a reminder that you have a
scheduled appointment for treatment or medical care,
This notice applies to the information and records we have
inform you of potential treatment alternatives or
about your health, health status, and the health care and
options, or inform you of health-related benefits that
service you receive from the Department in your personal
may be of interest to you.
file. It describes the information privacy practices followed
volunteers, staff and other office
by our employees,
personnel.
We may not use or disclose your information in the
It will tell you about the ways in which we may
following circumstances without your authorization:
use and disclose health information about you and describes
*Psychotherapy Notes - Any use or disclosure of
your rights and our obligations regarding the use and
psychotherapy notes, unless the notes are being used for
disclosure of that information. We are required by law to
treatment, payment, or health care operations, including
notify you of our legal duties and privacy
practices with
mental health training programs, oversight compliance,
respect to your health information. We are also required to
research purposes, or as part of a legal defense.
maintain the privacy of your protected health information in
*Marketing - Any use or disclosure for marketing
our custody, and to follow the terms of
this notice. If there is
purposes, except for face-to-face communication or
a breach involving your protected health information, we
promotional gifts to the individual.
will notify you no later than 60 days following the discovery
*Sale of Information - Any sale of protected health
of the breach. The Department is required to abide by the
information to a third party. We may not exchange your
terms of the notice of privacy practices that is currently in
protected health information to a third party for money
effect.
unless you consent.
There are special situations which allow us to use or
Uses and Disclosures of Your Protected Health
disclose your protected health information without your
Information
permission. These situations include:
* To Avert Serious Threat to Health or Safety - to prevent
We may use or disclose your protected health information
a serious threat to the health and safety of yourself, the public
for the following purposes:
or another person. We may disclose information to a family
*Treatment - to provide you with medical treatment or
member or a close friend if necessary to assist you in a life-
services and to manage and coordinate your medical
threatening emergency.
care. For example, your protected health information
* Required by Law - when required by federal, state or local
may be disclosed to a business associate of the
law, we must disclose or use your information to the extent
Department to determine your medical eligibility for
required.
Medicaid long-term-care services.
* Research - for research projects that benefit elders in
*Payment - to bill and collect payment for your health-care
Florida. The Department may disclose your information for
services. We may disclose or use your protected health
research projects that have been approved by an institutional
information to obtain or justify payment for your health-care
review board or privacy board that has analyzed the research
services from various payment sources including federal and
proposal to review the effect of the research on your privacy
state funding programs such as Medicaid.
rights and related interests.
*Health care operations - to evaluate the performance
* Organ and Tissue Donation - we may release information
of our staff in caring for you and to help us decide what
to organizations that handle procurement or transplantation,
additional services we should offer, how we can become
such as an organ donation bank, as necessary to facilitate
more efficient, or whether certain new treatments are
Florida Department of Elder Affairs
September 22, 2013
APPENDIX MM
Notice of Privacy Practices
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
Effective Date: September 22, 2013
effective. We may also use your protected health
Department of Elder Affairs’ Duties
information to: contact you as a reminder that you have a
scheduled appointment for treatment or medical care,
This notice applies to the information and records we have
inform you of potential treatment alternatives or
about your health, health status, and the health care and
options, or inform you of health-related benefits that
service you receive from the Department in your personal
may be of interest to you.
file. It describes the information privacy practices followed
volunteers, staff and other office
by our employees,
personnel.
We may not use or disclose your information in the
It will tell you about the ways in which we may
following circumstances without your authorization:
use and disclose health information about you and describes
*Psychotherapy Notes - Any use or disclosure of
your rights and our obligations regarding the use and
psychotherapy notes, unless the notes are being used for
disclosure of that information. We are required by law to
treatment, payment, or health care operations, including
notify you of our legal duties and privacy
practices with
mental health training programs, oversight compliance,
respect to your health information. We are also required to
research purposes, or as part of a legal defense.
maintain the privacy of your protected health information in
*Marketing - Any use or disclosure for marketing
our custody, and to follow the terms of
this notice. If there is
purposes, except for face-to-face communication or
a breach involving your protected health information, we
promotional gifts to the individual.
will notify you no later than 60 days following the discovery
*Sale of Information - Any sale of protected health
of the breach. The Department is required to abide by the
information to a third party. We may not exchange your
terms of the notice of privacy practices that is currently in
protected health information to a third party for money
effect.
unless you consent.
There are special situations which allow us to use or
Uses and Disclosures of Your Protected Health
disclose your protected health information without your
Information
permission. These situations include:
* To Avert Serious Threat to Health or Safety - to prevent
We may use or disclose your protected health information
a serious threat to the health and safety of yourself, the public
for the following purposes:
or another person. We may disclose information to a family
*Treatment - to provide you with medical treatment or
member or a close friend if necessary to assist you in a life-
services and to manage and coordinate your medical
threatening emergency.
care. For example, your protected health information
* Required by Law - when required by federal, state or local
may be disclosed to a business associate of the
law, we must disclose or use your information to the extent
Department to determine your medical eligibility for
required.
Medicaid long-term-care services.
* Research - for research projects that benefit elders in
*Payment - to bill and collect payment for your health-care
Florida. The Department may disclose your information for
services. We may disclose or use your protected health
research projects that have been approved by an institutional
information to obtain or justify payment for your health-care
review board or privacy board that has analyzed the research
services from various payment sources including federal and
proposal to review the effect of the research on your privacy
state funding programs such as Medicaid.
rights and related interests.
*Health care operations - to evaluate the performance
* Organ and Tissue Donation - we may release information
of our staff in caring for you and to help us decide what
to organizations that handle procurement or transplantation,
additional services we should offer, how we can become
such as an organ donation bank, as necessary to facilitate
more efficient, or whether certain new treatments are
Florida Department of Elder Affairs
September 22, 2013
APPENDIX MM
organ or tissue donation and transplantation.
use or disclose information about you for the purposes
covered by your written authorization. However, we
* Current or Previous Military, Veterans, National
cannot take back any uses or disclosures already made with
Security and Intelligence Members - when required by
your permission.
military command or other government authorities. We may
also release information about foreign military personnel to
If we have HIV or substance abuse information about you,
the appropriate foreign military authority.
we cannot release that information without a special signed,
* Workers’ Compensation - as authorized by and to the
written authorization from you. This is different than the
extent necessary to comply with laws relating to workers’
authorization and consent mentioned above.
compensation or similar programs. Such programs provide
In order to disclose HIV or substance abuse records for
benefits for work-related injuries or illness.
purposes of treatment, payment, or health care operations, we
* Public Health Risks - to public health or other authorities
will need both your signed consent and a special written
charged with preventing or controlling disease, injury or
authorization that complies with the law governing those
disability. We may also disclose your information to report
records.
births, deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications or problems with
Individual Rights
FDA-regulated products.
* Health Oversight Activities - for audits, investigations,
You have the right to inspect and copy your protected
inspections, licensing purposes, or other activities necessary
health information. In order to do so, you must submit a
for appropriate oversight, as authorized by law. These
written request to inspect and/or copy your protected health
disclosures may be necessary for certain state and federal
information. Your request may be denied in certain limited
agencies to monitor the health-care system, government
circumstances. However, if your request is denied, you may
programs, and compliance with civil rights laws.
ask that the denial be reviewed. We will comply with the
* Lawsuits and Disputes - in response to a court or adminis-
outcome of the review. As provided by 45 CFR §164.524,
trative order. Subject to all applicable legal requirements, we
reasonable copy fees shall apply in accordance with State law.
may also disclose protected health information about you in
response to a subpoena. We may also use or disclose your
You have the right to request a correction or change to
information to defend ourselves in the event of a lawsuit or
your protected health information if you believe it is
administrative proceeding.
incorrect or incomplete, as provided by 45 CFR
* Law Enforcement - for law enforcement purposes if
§164.526. Your request must be in writing and include a
required to do so by a law enforcement official in response to
reason to support the request. We may deny your request if
a court order, subpoena, warrant, summons or similar
you ask us to amend information that:
process, subject to all applicable legal requirements.
a) we did not create, unless the person or entity that created
* Coroners, Medical Examiners and Funeral
the information is no longer available to make the amend-
Directors - to identify a deceased person or determine the
ment;
cause of death. We may disclose your information to
b) is not part of the health information that we keep; and/or
report vital events such as death, as permitted or required
c) you would not be permitted to inspect and copy.
by law.
* Volunteers - to volunteers performing work for the
You have the right to request an accounting of disclo-
Department, including, but not limited to, volunteers in
sures, as provided by 45 CFR §164.528. This is a list of
programs such as SHINE, Sunshine for Seniors and State
the disclosures we made of medical information about you
Long-Term Care Ombudsman.
for purposes other than treatment, payment and health care
* Information Not Personally Identifiable - we may
operations. You may request an accounting of disclosures
disclose health information that does not personally identify
for a period up to six years prior to the date of your request.
you or reasonably reveal who you are.
You must submit your request in writing. You are entitled
*Fundraising Activities - to contact you for
to obtain one free copy of the accounting per 12-month
fundraising activities. You may elect not to receive
period. For each additional request, we may charge you for
fundraising communications by contacting the Privacy
the costs of providing the list, whether it is provided
Officer in the Office of General Counsel.
electronically or by paper copy. However, you may choose to
withdraw or modify your request before any costs are
Other Uses and Disclosures
incurred.
We will not use or disclose your protected health
information for any purpose that is not addressed in this
notice without your specific, written authorization. If you
give us authorization, you may revoke it, in writing, at any
time. If you revoke your authorization, we will no longer
Florida Department of Elder Affairs
September 22, 2013
APPENDIX MM
You have the right to request to receive communications of
For Further Information
Requests for further information about topics covered in this
protected health information by alternative means or at
alternative locations, as provided by 45 CFR 164.522(b).
notice may be directed towards the person who gave you the
You may request that we communicate with you about medical
notice or to the Department of Elder Affairs, Privacy Officer,
matters in a certain way or at a certain location.
Office of the General Counsel at 4040 Esplanade Way,
Tallahassee, FL, 32399-7000 or by phone at (850) 414-
2000.
You have the right to request a restriction or limitation
on the health information we use or disclose about you
for treatment, payment or health care operations as
provided by 45 CFR §164.522(a). If we agree to a
requested restriction, we will comply with your request
unless the information is needed to provide you emergency
treatment.
You have the right to a paper copy of this notice. If you
have agreed to receive it electronically, you are still entitled
to a paper copy upon request to the Privacy Officer in the
Office of the General Counsel.
Changes to This Notice
We reserve the right to change this notice, and to make the
revised or changed notice effective for medical information
we already have about you as well as any information we
receive in the future. If this notice is revised or changed, we
will post a summary of the current notice in the Department
with its effective date. An up-to-date copy of this notice is
available electronically on our website at
www.elderaffairs.state.fl.us. You are entitled to a copy of the
notice currently in effect.
Complaints
If you believe your privacy rights have been violated, you
may file a complaint with our office or with the Secretary of
the U.S. Department of Health and Human Services. You
will not be retaliated against for filing a complaint. To file a
complaint with our office or the Secretary of the U.S.
Department of Health and Human Services, contact:
Privacy Officer, Office of the General Counsel
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
Voice Phone: (850) 414-2000
FAX: (850) 414-2004
TDD: (850) 414-2001
Region IV, Office for Civil Rights
U.S. Department of Health and Human Services
Sam Nunn Atlanta Federal Center, Suite 3870
61 Forsyth Street S.W.
Atlanta, Georgia 30303-8909
Voice Phone: (800) 368-1019
FAX: (404) 562-7881
TDD: (800) 537-7697
Florida Department of Elder Affairs
September 22, 2013
APPENDIX MM
I hereby acknowledge that I have received and read this Notice of Privacy Practices.
Signature
Printed Name
Date (DD/MM/YYYY)
Florida Department of Elder Affairs
September 22, 2013
APPENDIX MM
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