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Business Office - 1170 Roosevelt Street Ext. - Dubuque, Iowa 52001 - (563) 556-7560 - fax (563) 556-7565
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Empowering people with mental disabilities to achieve their highest quality of life.
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NOTICE OF PRIVACY PRACTICES
Area Residential Care, Inc.
1170 Roosevelt Street Extension
Dubuque, Iowa 52001
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact the agency’s
Privacy Officer (Associate Director) at 563-556-7560.
______________________________________________________________________
This Notice of Privacy Practices describes how we may use and disclose your protected
health information to carry out treatment, payment, or health care operations and for
other purposes that are permitted or required by law. This Notice also describes your
rights regarding health information we maintain about you and a brief description of how
you may exercise these rights. This Notice further states the obligations we have to
protect your health information.
“Protected health information” means health information (including identifying information
about you) we have collected from you or received from your health care providers, health
plans, your employer, or a health care clearinghouse. It may include information about
your past, present, or future physical or mental health or condition, the provision of your
health care, and payment for your health care services.
We are required by law to maintain the privacy of your health information and to provide
you with this notice of our legal duties and privacy practices with respect to your health
information. We are also required to comply with the terms of our current Notice of
Privacy Practices.
How We Will Use and Disclose Your Health Information
We will use and disclose your health information for treatment, payment, and operations.
For example:
For Treatment. We will use and disclose your health information without your
authorization, except when authorization is required by our licensing, funding, and
accrediting organizations, to provide your health care and any related services. We will
also use and disclose your health information to coordinate and manage your health care
and related services. For example, we may need to disclose information to a case
manager who is responsible for coordinating your care.
We may disclose your health information among our staff who work at Area Residential
Care (including staff who are not your principal staff, but who substitute in case of
vacancies, vacations, or the like). We will disclose your health information to agency
volunteers or unpaid interns only with your written permission.
We may disclose your health information to staff and others working outside of Area
residential Care who serve on agency committees that impact you. For example members
of the agency’s Human Rights Committee may discuss your health information for
purposes of determining appropriateness of restrictive programming.
In addition, we may disclose your health information without your authorization to another
health care provider (e.g., your primary care physician or a laboratory) working outside of
Area Residential Care for purposes of your treatment.
For Payment. We may use or disclose your health information without your
authorization, except when authorization is required by our licensing, funding, and
accrediting organizations, so that the treatment and services you receive are billed to, and
payment is collected from, your health plan or other third party payer. By way of example,
we may disclose your health information to permit your third party payer to take certain
actions before your third party payer approves or pays for your services. These actions
may include:
• making a determination of eligibility or coverage;
• reviewing your services to determine if they were necessary;
• reviewing your services to determine if they were appropriately authorized or
certified in advance of your care; or
• reviewing your services for purposes of utilization review, to ensure
appropriateness of your care, or to justify the charges for your care.
For example, your third party payer may ask us to share your health information in order
to determine if the payer will approve additional visits to your therapist. We may also
disclose your health information to another health care provider so that provider can bill
you for services they provided to you, for example an ambulance service that transported
you to the hospital.
For Operations. We may use and disclose health information about you without your
authorization, except when authorization is required by our licensing, funding, and
accrediting organizations, for our health care operations. These uses and disclosures are
necessary to run our organization and make sure that our consumers receive quality
care. These activities may include, by way of example, quality assessment and
improvement, reviewing the performance or qualifications of our staff; licensing;
accreditation; business planning and development; and general administrative activities.
We may combine health information of many of our consumers to decide what additional
services we should offer, what services are no longer needed, and whether certain
treatments are effective.
We may also provide your health information to other health care providers or to your
third party payer to assist them in performing certain of their own health care operations.
We will do so only if you have or have had a relationship with the other provider or health
plan. For example, we may provide information about you to your third party payer to
assist them in their quality assurance activities.
We may also use and disclose your health information to contact you to remind you of
health- and care-related appointments, through such means as letters, answering
machines, etc.
Finally, we may use and disclose your health information to inform you about possible
treatment options or alternatives that may be of interest to you.
Residential/Vocational Rosters. We maintain rosters at the administrative offices,
within our residential facilities and at our vocational sites for the purpose of allowing staff
to locate you. These rosters are only provided to agency staff; licensing, funding, and
accrediting personnel; and Resident Advocate Committee members. (Resident Advocate
Committee members are not employed by Area Residential Care.) These rosters include
your name, residential address or vocational program, residential phone number, your
responsible party’s phone number, and staff assigned to work with you. These rosters
are necessary for the agency to conduct its business and for the agency’s staff and
advocate committee to perform their duties in regard to your care, treatment, and training.
Other Health-Related Benefits and Services. We may use and disclose health
information to tell you about health-related benefits or services that may be of interest to
you. If you do not want us to provide you with information about health-related benefits or
services, you must notify the Privacy Officer in writing at 1170 Roosevelt Street Extension,
Dubuque, Iowa 52001. Please state clearly that you do not want to receive materials
about health-related benefits or services.
Fundraising Activities. We may use or disclose health information about you to contact
you about raising money for our programs, services and operations. We may disclose
health information to our fundraising entity, the Development Director and his/her advisory
board, so that they may contact you to raise money for us. If we disclose such
information, we will only release basic contact information, such as your name and
address and the dates you were provided service, but we will not provide information
about your treatment. If you do not want us to contact you for fundraising purposes, you
must notify the Privacy Officer in writing at 1170 Roosevelt Street Extension, Dubuque,
Iowa 52001. Please state clearly that you do not want to receive any fundraising
solicitations from us.
We will not use your health information for agency marketing or fundraising activities
without your written authorization.
Uses and Disclosures That May Be Made Without Your Authorization, But For
Which You Will Have an Opportunity to Object
Persons Involved in Your Care. We may provide health information about you to
someone who helps pay for your care. We may use or disclose your health information to
notify or assist in notifying a family member, personal representative, or any other person
who is responsible for your care, of your location, general condition, or in the event of
your death. We may also use or disclose your health information to an entity assisting in
disaster relief efforts and to coordinate uses and disclosures for this purpose to family or
other individuals involved in your health care.
In limited circumstances, we may disclose health information about you to a friend or
family member who is involved in your care. If you are physically present and have the
capacity to make health care decisions, your health information may only be disclosed
with your agreement to persons you designate to be involved in your care.
But, if you are in an emergency situation, we may disclose your health information to a
spouse, a family member, or a friend so that such person may assist in your care. In this
case we will determine whether the disclosure is in your best interest and, if so, only
disclose information that is directly relevant to participation in your care. And, if you are
not in an emergency situation but are unable to make health care decisions, we will
disclose your health information to:
• a person designated to participate in your care in accordance with an advance
directive validly executed under state law,
• your guardian or other legal representative, if one has been appointed by a court, or
• if applicable, the state agency responsible for consenting to your care.
Uses and Disclosures That May Be Made Without Your Authorization or
Opportunity to Object
Emergencies. We may use and disclose your health information in an emergency
treatment situation. By way of example, we may provide your health information to a
paramedic who is transporting you in an ambulance. If a clinician is required by law to
treat you and your treating clinician has attempted to obtain your authorization but is
unable to do so, the treating clinician may nevertheless use or disclose your health
information to treat you.
Research. We may disclose your health information to researchers when their research
has been approved by an Institutional Review Board or a similar privacy board that has
reviewed the research proposal and established protocols to protect the privacy of your
health information.
As Required by Law. We will disclose health information about you when required to do
so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health
information about you when necessary to prevent a serious and imminent threat to your
health or safety or to the health or safety of the public or another person. Under these
circumstances, we will only disclose health information to someone who is able to help
prevent or lessen the threat.
Organ and Tissue Donation. If you are an organ donor, we may release your health
information to an organ procurement organization or to an entity that conducts organ, eye
or tissue transplantation, or serves as an organ donation bank, as necessary to facilitate
organ, eye or tissue donation and transplantation.
Public Health Activities. We may disclose health information about you as necessary
for public health activities including, by way of example, disclosures to:
• report to public health authorities for the purpose of preventing or controlling
disease, injury, or disability;
• report vital events such as birth or death;
• conduct public health surveillance or investigations;
• report child abuse or neglect;
• report certain events to the Food and Drug Administration (FDA) or to a person
subject to the jurisdiction of the FDA including information about defective products
or problems with medications;
• notify consumers about FDA-initiated product recalls;
• notify a person who may have been exposed to a communicable disease or who is
at risk of contracting or spreading a disease or condition;
• notify the appropriate government agency if we believe you have been a victim of
abuse, neglect or domestic violence.
Health Oversight Activities. We may disclose health information about you to a health
oversight agency for activities authorized by law. Oversight agencies include government
agencies that oversee the health care system, government benefit programs such as
Medicare or Medicaid, other government programs regulating health care, and civil rights
laws.
Disclosures in Legal Proceedings. We may disclose health information about you to a
court or administrative agency when a judge or administrative agency orders us to do so.
We also may disclose health information about you in legal proceedings without your
permission or without a judge or administrative agency’s order when we receive a
subpoena for your health information.
Law Enforcement Activities. We may disclose health information to a law enforcement
official for law enforcement purposes when:
• a court order, subpoena, warrant, summons or similar process requires us to do so;
or
• the information is needed to identify or locate a suspect, fugitive, material witness,
or missing person; or
• we report a death that we believe may be the result of criminal conduct; or
• we report criminal conduct occurring on the premises of our facility; or
• we determine that the law enforcement purpose is to respond to a threat
imminently dangerous activity by you against yourself or another person; or
• the disclosure is otherwise required by law.
We may also disclose health information about you, without a court order or without being
required to do so by law, if you are a victim of a crime. However, we will do so only if the
disclosure has been requested by a law enforcement official and you agree to the
disclosure or, in the case of your incapacity, the following occurs:
• the law enforcement official represents to us that (i) the you are not the subject of
the investigation and (ii) an immediate law enforcement activity to meet a serious
danger to you or others depends upon the disclosure; and
• we determine that the disclosure is in your best interest.
Medical Examiners or Funeral Directors. We may provide health information about
you to a medical examiner. Medical examiners are appointed by law to assist in
identifying deceased persons and to determine the cause of death in certain
circumstances. We may also disclose health information about you to funeral directors as
necessary to carry out their duties.
Military and Veterans. If you are a member of the armed forces, we may disclose your
health information as required by military command authorities. We may also disclose
your health information for the purpose of determining your eligibility for benefits provided
by the Department of Veterans Affairs. Finally, if you are a member of a foreign military
service, we may disclose your health information to that foreign military authority.
National Security and Protective Services for the President and Others. We may
disclose medical information about you to authorized federal officials for intelligence,
counter-intelligence, and other national security activities authorized by law. We may also
disclose health information about you to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state or so they
may conduct special investigations.
Workers’ Compensation. We may disclose health information about you to comply with
the state’s Workers’ Compensation Law.
Uses and Disclosures of Your Health Information with Your Permission
Uses and disclosures not described in the aforementioned text of this Notice of Privacy
Practices will generally only be made with your written permission, called an
“authorization” or release of information. You have the right to revoke an
authorization/release at any time. If you revoke your authorization/release we will not
make any further uses or disclosures of your health information under that
authorization/release, unless we have already taken an action relying upon the uses or
disclosures you have previously authorized.
Your Rights Regarding Your Health Information
Right to Inspect and Copy. You have the right to request an opportunity to inspect or
copy health information used to make decisions about your care – whether they are
decisions about your treatment or payment of your care. Usually, this would include
clinical and billing records, but not psychological reports. You must submit your request in
writing to our Privacy Officer at 1170 Roosevelt Street Extension, Dubuque, Iowa 52001.
If you request a copy of the information, we may charge a fee for the cost of copying,
mailing, and supplies associated with your request.
We may deny your request to inspect or copy your health information in certain limited
circumstances. In some cases, you will have the right to have the denial reviewed by a
licensed health care professional not directly involved in the original decision to deny
access. We will inform you in writing if the denial of your request may be reviewed. Once
the review is completed, we will honor the decision made by the licensed health care
professional reviewer.
Right to Amend. For as long as we keep records about you, you have the right to
request us to amend any health information used to make decisions about your care,
whether they are decisions about your treatment or payment of your care. Usually, this
would include clinical and billing records, but not psychological reports. To request an
amendment, you must submit a written document to our Privacy Officer at 1170 Roosevelt
Street Extension, Dubuque, Iowa 52001 and tell us why you believe the information is
incorrect or inaccurate. We may deny your request for an amendment if it is not in writing
or does not include a reason to support the request. We may also deny your request if
you ask us to amend health information that:
• was not created by us, unless the person or entity that created the health
information is no longer available to make the amendment;
• is not part of the health information we maintain to make decisions about your care;
• is not part of the health information that you would be permitted to inspect or copy;
• is accurate and complete.
If we deny your request to amend, we will send you a written notice of the denial stating
the basis for the denial and offering you the opportunity to provide a written statement
disagreeing with the denial. If you do not wish to prepare a written statement of
disagreement, you may ask that the requested amendment and our denial be attached to
all future disclosures of the health information that is the subject of your request.
If you choose to submit a written statement of disagreement, we have the right to prepare
a written rebuttal to your statement of disagreement. In this case, we will attach the written
request and the rebuttal (as well as the original request and denial) to all future
disclosures of the health information that is the subject of your request.
Right to an Accounting of Disclosures. You have the right to request that we provide
you with an accounting of disclosures we have made of your health information. An
accounting is a list of disclosures. But this list will not include certain disclosures of your
health information, for example, those we have made for purposes of treatment, payment,
and health care operations. To request an accounting of disclosures, you must submit
your request in writing to the Privacy Officer at 1170 Roosevelt Street Extension,
Dubuque, Iowa 52001. For your convenience, you may submit your request on a form
called a Request For Accounting of PHI Disclosed by Area Residential Care, which you
may obtain from our Privacy Officer. The request should state the time period for which
you wish to receive an accounting. This time period should not be longer than six years
and not include dates before April 14, 2003.
The first accounting you request within a twelve-month period will be free. For additional
requests during the same 12-month period, we will charge you for the costs of providing
the accounting. We will notify you of the amount we will charge and you may choose to
withdraw or modify your request before we incur any costs.
Right to Request Restrictions. You have the right to request a restriction on the
health information we use or disclose about you for treatment, payment, or health care
operations. To request a restriction, you must request the restriction in writing addressed
to the Privacy Officer at 1170 Roosevelt Street Extension, Dubuque, Iowa 52001. The
Privacy Officer will ask you to sign a Request for Restriction form, which you should
complete and return to the Privacy Officer. We are not required to agree to a restriction
that you may request. If we do agree, we will honor your request unless the restricted
health information is needed to provide you with emergency treatment.
Right to Request Confidential Communications. You have the right to request that
we communicate with you about your health care only in a certain location or through a
certain method. For example, you may request that we contact you only at work or by e-
mail. To request such a confidential communication, you must make your request in
writing to the Privacy Officer at 1170 Roosevelt Street Extension, Dubuque, Iowa 52001.
We will accommodate all reasonable requests. You do not need to give us a reason for
the request; but your request must specify how or where you wish to be contacted.
Right to a Paper Copy of this Notice. You have the right to obtain a paper copy of this
Notice of Privacy Practices at any time. Even if you have agreed to receive this Notice of
Privacy Practices electronically, you may still obtain a paper copy. To obtain a paper
copy, contact our Privacy Officer at 1170 Roosevelt Street Extension, 563-556-7560.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or
with the Secretary of the U.S. Department of Health and Human Services. To file a
complaint with us, contact our Complaint Officer (Human Resources Director), who is
responsible for receiving complaints, at 1170 Roosevelt Street Extension, 563-556-7560.
All complaints must be submitted in writing. Our Privacy Officer (Associate Director), who
can be contacted at 1170 Roosevelt Street Extension, 563-556-7560 will assist you with
writing your complaint, if you request such assistance.
We will not retaliate against you for filing a complaint.
Changes to this Notice
We reserve the right to change the terms of our Notice of Privacy Practices. We also
reserve the right to make the revised or changed Notice of Privacy Practices effective for
all health information we already have about you as well as any health information we
receive in the future. We will post a copy of the current Notice of Privacy Practices at our
main office and at each owned or leased site, where we provide services. You may also
obtain a copy of the current Notice of Privacy Practices by calling us at 563-556-7560 and
requesting that a copy be sent to you in the mail or by asking for one from your IPC, your
staff, the Quality Services Coordinator, or the Privacy Officer (Associate Director).
Effective date: March 15, 2007