VILLAGE NORTHWEST UNLIMITED 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.
If you have any questions about this notice, please contact our Privacy Officer, who is the Director of ICF/ID & Program Services at Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201 telephone number (712)324-4873.
This notice 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. In this document “you” is the person who receives services from Village Northwest Unlimited. If the legal guardian or parent, “you” refers to the person for whom you are legal guardian or parent. “Protected health information (also referred to above as medical information)” is information about you, including demographic information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. This notice also describes your rights to and our duties with respect to protected health information. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
Unless you request otherwise, in writing, we may contact you, or your legal guardian, by telephone, or by mail, or by e-mail, at either home or workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate to you in a certain way or at a certain location, please see the section labeled “Right to Receive Confidential Communications” in this document.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. If revised, the Notice of Privacy Practices will be made available to you, upon request. We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice. A copy of our current Notice of Privacy Practices will be posted at Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201. A copy of the current notice also will be posted on our web site, www.villagenorthwest.org At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting: Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201, telephone number (712)324-5406.
How We May Use and Disclose Health Information About You
We use and disclose health information about you for a number of different purposes. Your protected health information may be used and disclosed by our staff and others outside of our agency that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the agency. Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make, without your written authorization. These examples are not meant to be exhaustive, but to provide examples of the types of uses and disclosures that we may undertake.
We may share health information about you to provide, coordinate, or manage the services, supports, and health care you receive from us, and other health care providers involved in your care. For example, we may share your protected health information with the physician, specialist, dentist, or optometrist who may be treating you, to ensure that he/she has the necessary information to provide care to you, and/or remind you of appointments. Staff may share information to arrange for, or coordinate needed services, such as medical tests, durable medical equipment, or case management. We may share protected health information about you, with any staff member or volunteer providing care to you. We may use and disclose health information about you to contact you about treatment and service alternatives, health-related benefits and services that may be of interest to you. As an example, we may contact you with information about a different level of care that may be of interest to you.
Your protected health information will be used, as needed, to obtain payment for your health care services. We may use and disclose health information about you so we can be paid for the services we provide to you. For example, we may need to provide the State of Iowa Medicaid program information about the services we provide to you, in order to demonstrate eligibility for services or to be reimbursed for services. This may also include certain activities that your health insurance plan may undertake before it approves or pays for health care services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for hospital admission.
Health Care Operations:
We may use or disclose your protected health information to support our own operations. These are necessary for us to operate Village Northwest Unlimited, and for quality maintenance. For example, we may use health information about you to review the services we provide, and the performance of our employees supporting you. We may disclose health information about you to train our staff and volunteers. We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program. For example, your protected health information may be utilized for quality assurance to determine patterns of, and for prevention of communicable disease, injury incidence, or medication usage patterns. Outside agencies, such as the Department of Inspection and Appeals, or Department of Human Services, or Iowa Medical Enterprises may access your private health information to evaluate the performance of our agency through audits, investigations, inspections, licensure, or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and evaluations of entities subject to various government regulations. We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
Family and Friends:
We may disclose private health information to your guardian, or other legal representative. We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, general health information about you that is directly relative to that person’s involvement with the services and supports you receive, or payment for those services and supports. We also may use or disclose health information about you to notify, or assist in notifying those persons of your location, general condition, or death. If there is a family member or other relative, or close personal friend that you do not want us to disclose health information to, please notify the Privacy Officer (Director of Health and Therapeutic Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201) in writing.
Other Uses and Disclosures That May Be Made Without Your Written Authorization
We may use or disclose your protected health information in the following situations without your consent or authorization. These types of disclosures will be documented on a disclosure log.
Victims of Abuse, Neglect or Domestic Violence:
We may disclose health information about you to a government authority (Department of Inspections and Appeals, Department of Human Services, law enforcement) authorized by law to receive reports of abuse, neglect or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is (a) required by law; (b) agreed to by you; or (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
Disclosures for Law Enforcement Purposes, or to Correctional Facilities:
We may disclose health information about you to a law enforcement official for law enforcement purposes. Examples may include to identify or locate a suspect, fugitive, material witness or missing person, about an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed. We may alert law enforcement about a death if we suspect the death may have resulted from criminal conduct, about any crimes that occurred at Village Northwest Unlimited, or to report a crime in emergency circumstances. We may disclose health information about you in response to a court, grand jury, administrative or judicial order, warrant, or subpoena. If you have been placed in a correctional facility, disclosure may be made to provide ongoing health care to you, for the health and safety of others, or for administration and maintenance of the safety, security, and good order of the correctional institution.
Public Health Activities or Disaster Relief:
We may disclose health information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. We may use or disclose medical information about you for public health activities and purposes, including reporting health information to a public health authority that is authorized by law to collect, or receive the information for purposes of preventing or controlling disease. As an example, Village Northwest Unlimited is required to report certain diseases (example: tuberculosis) to the O’Brien County Public Health. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of the Food and Drug Administration-regulated product or activity.
To Your Employer:
We may use or disclose medical information to your employer if the information is to fulfill your employer’s responsibilities related to a work place injury. We will provide written notice to you that the information is being disclosed to your employer.
To Avert Serious Threat to Health and Safety:
We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We may also release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from lawful custody.
Required by Law:
We may use or disclose health information about you when we are required to do so by state or federal law.
Organ, Eye or Tissue Donation:
To facilitate organ, eye or tissue donation and transplantation, we may disclose health information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes, or tissue.
We may disclose health information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death. We may disclose health information about you to funeral directors as necessary for them to carry out their duties.
National Security and Intelligence:
We may disclose health information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law, including for the protection of our President.
We may use and disclose your private health information for the purpose of determination by the Department of Veterans Affairs for your eligibility for benefits.
OTHER USES AND DISCLOSURES:
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying, in writing, the Privacy Officer (Director of Health and Therapeutic Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201). If you do choose to revoke authorization that revocation will not have any effect on actions taken prior to the revocation.
Fundraising and Public Relations
Photographs, videotapes, audiotapes or other visual, audio, or digital images may be taken of you, and articles about your personal accomplishments may be written about you, including information about your diagnosis and response to treatments and services received. These may be used by Village Northwest Unlimited in the following ways, if and only if, you have given your written consent: education, publicity, fundraising, and marketing. If you do not want Village Northwest Unlimited to contact you for fund-raising and public relations activities, you must notify the Director of Advancement at Village Northwest Unlimited, in writing. At no time will your protected health information be sold.
Under certain circumstances, we may use or disclose health information about you for research. Before we disclose health information for research, the research will have been approved through a process that involves consent from you or your legal guardian, consent from the Village Northwest Unlimited Human Rights Committee, and evaluates the needs of the research project against your needs for privacy of your health information.
Your authorization is required before we may use or disclose psychotherapy notes unless the use or disclosure is (a) by the originator of the notes for treatment; (b) to defend ourselves in a legal action or other proceeding brought by you; (c) when required by law; or (e) permitted by law for oversight of the originator of the psychotherapy notes.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization at any time by notifying Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon IA 51201. However, if you revoke such an authorization it will not have any effect on actions taken by us in reliance on it.
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise your rights.
You Have the Right to Inspect and Copy Your Protected Health Information.
With a few very limited exceptions, such as psychotherapy notes, you have the right to inspect and obtain a copy of medical information about you. To inspect or copy medical information about you, you must submit your request in writing to: Privacy Officer, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201. Your request should state specifically what medical information you want to inspect or copy. Your request should state the form of access and copy you desire, such as in paper or in electronic media. If you request a copy of the information, we may charge a fee for the costs of copying, and if you ask that it be mailed, the cost of mailing. We usually will act on your request within thirty calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. If you request a review of our denial, it will be conducted by a licensed health care professional designated by us who was not directly involved in the denial. We will comply with the outcome of that review.
You Have the Right to Amend Your Protected Health Information:
This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. Your request must be submitted in writing to Privacy Officer, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201, state the amendment desired and provide a reason in support of that amendment. We will act upon your request within sixty days. If we grant your request, in whole or in part, we will inform you of our acceptance of your request. We will make the appropriate amendment to your health information by appending or otherwise providing a link to the amendment. We will inform you of our acceptance of your request and provide access and copying.
In certain cases, we may deny your request for an amendment. Reasons for denial may include requests for amending health information that was not created by us, is not part of the health information maintained by us, or is accurate and complete. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Any subsequent disclosure of the information will include the request, denial, statement of disagreement, and rebuttal statement. If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the medical information involved. You also will have the right to complain about our denial of your request. Please contact our Privacy Officer (Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201) if you have any questions about amending your medical record.
You Have the Right to Request a Restriction of Disclosure of Your Protected Health Information.
This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must include what information you want to limit, and to whom you want the limitations to apply. As an example, you may choose to limit who attends your Individualized Comprehensive Plan meeting. Any requests to restrict disclosure should be made in writing to the Privacy Officer (Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201).
With one exception, we are not required to agree to any requested restriction. The exception is that Village Northwest Unlimited will agree to the request of an individual to restrict disclosure of protected health information, to a health plan, if the disclosure is (a) for the purpose of carrying out payment or health care operations, and is not otherwise required by law, and (b) the information relates solely to a health care item or service for which you, or someone on your behalf (other than the health plan), has paid us in full.
If we agree to a restriction, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction. However, we will not terminate a restriction that falls into the exception stated in the previous paragraph.
You Have the Right to Request to Receive Confidential Communications From Us by Alternative Means, or at Alternative Locations.
You have the right to request that we communicate health information about you, to you, in a certain way or at a certain location. For example, you can ask that we contact you by phone only at home (not at work). We will accommodate reasonable requests. We may also condition this accommodation by asking you to pay a reasonable fee to accommodate this request. We may request an alternative address or other method of contract. We will not request an explanation from you as to the basis for the request. Please make requests in writing to our Privacy Officer, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201. Your request must state how to contact you.
You Have the Right to Receive an Accounting of Certain Disclosures We Have Made, If Any, of Your Protected Health Information.
The accounting of disclosures may be for up to six years prior to the date on which you request the accounting, but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting:
Disclosures to carry out treatment, payment and health care operations, as described in the Notice of Privacy Practices.
Disclosures of your health information to you, or legal guardian, or other legal representative.
Disclosures that you have authorized.
Disclosures to family/friends.
Disclosures for our facility directory or to persons involved in your care.
Disclosures for disaster relief purposes, for national security or intelligence purposes.
Disclosures to correctional institutions or law enforcement officials having custody of you.
Disclosures made prior to April 14, 2003.
To receive an accounting of these disclosures, contact the Privacy Officer at Village Northwest Unlimited. Your request must state a time period for the disclosures. It may not be longer than six years prior to the date that we received your request. We will act on your request within sixty days of your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when the accounting will be provided, and reason for delay.
You Have the Right to Receive a Copy of This Notice.
A copy of this Privacy Notice will be made available to you upon request. You may request a paper copy of our Notice of Privacy Practices at any time, even if you previously agreed to receive the notice electronically. To obtain a copy, contact the Privacy Officer at (712)324-4873, or send your request to the Privacy Officer (Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201). You may also view a copy of our Notice of Privacy Practice over the internet, at our web site, www.villagenorthwest.org .
You have the Right to Complain.
You may contact the Privacy Officer at (712)324-4873, or send your complaint to the Privacy Officer (Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201).
You may complain to the United States Secretary of Health and Human Services, Office of Civil Rights, 200 Independence Avenue SW, Washington DC 20201 if you believe your privacy rights have been violated by us. Village Northwest Unlimited will take no retaliatory action based on your complaint.
DUTIES OF VILLAGE NORTHWEST UNLIMITED
We are required by law to maintain the privacy of health information about you, and to provide individuals with notice of our legal duties and privacy practices with respect to health information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.
A copy of your current Notice of Privacy Practices will be posted at the Wansink Center, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA. A copy of our current notice also will be posted on our web site www.villagenorthwest.org At any time you may obtain a copy of the current Notice of Privacy Practices by contacting the Privacy Officer (Director of ICF/ID & Program Services, Village Northwest Unlimited, 330 Village Circle, Sheldon, IA 51201, phone 712-324-4873).