POLICY

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

The Community of The Good Shepherd shall follow all applicable laws to assure the privacy and confidentiality of the protected health information (PHI) of those individuals who receive supports and services from this agency.

PROCEDURE

2. The privacy notice must include the following information:

1. How medical information (protected health information - PHI) about a consumer may be used and disclosed and how a consumer and/or guardian may get access to this information.
2. A description, and example, of types and uses of disclosures for each of the following purposes - treatment, payment, and health care operations.
3. A description of other purposes Community of The Good Shepherd is either required or permitted to use or disclose PHI without written consent or authorization.
4. A statement that other uses and disclosures will be made only with written authorization from the consumer or guardian and may be revoked at any time.
5. A statement of the rights with respect to uses and disclosures of PHI and a description of how they may be exercised including:

• 1) the right to receive confidential communications of PHI
• 2) the right to inspect and copy PHI
• 3) the right to amend PHI
• 4) the right to receive accountings of disclosures of PHI; and
• 5) the right to obtain a paper copy of this notice upon request.

6. A statement about Community of The Good Shepherd's duties to:

• 1) maintain the privacy of PHI
• 2) abide by the terms of the privacy notice currently in effect
• 3) notify consumers when any changes are made to the privacy statement

7. A statement that individuals may notify Community of The Good Shepherd or DHHS if they believe their rights have been violated; a brief description of how to file a complaint and a statement that there will be no retaliation against the individual if a complaint is made.
8. The name, title and telephone number of the person or office designated as responsible for receiving complaints and providing additional information.
9. The date on which the notice is first in effect.

3. The privacy notice will be reviewed with persons receiving services and/or guardians as part of the initial orientation to services with Community of The Good Shepherd.

4. The privacy notice will be reviewed annually with all persons served, or more often if changes are made.

COMMUNITY OF THE GOOD SHEPHERD NOTICE OF PRIVACY PRACTICES

Persons Served

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.

Use and disclosure of Your Medical Information:

Community of The Good Shepherd uses your medical information (Protected Health Information, PHI), to provide you with residential habilitation services, to receive payment for those services and to assure your daily health needs are met.

Treatment: Community of The Good Shepherd may disclose your medical information to those involved in your treatment such as Community of The Good Shepherd staff, your service coordinator, other staff, and volunteers who work directly with you.

Health Care Operations: Community of The Good Shepherd may disclose your medical information to your doctor and dentist, and any other health care providers. Community of The Good Shepherd staff may pick up/or sign for your medical prescriptions and other documents (medical supplies, x-rays, etc.) related to your care.

Payment: Community of The Good Shepherd may be required to use or disclose your medical information in order to obtain payment for services you receive through our agency.

Additional Uses and Disclosures That Do Not Require Your Consent:

In certain situations, your consent is not required for the use or disclosure of your medical information. Those situations are described below:

• Community of The Good Shepherd may disclose your medical information to a public health authority in order to prevent or control disease, to report birth or death, and for the purpose of public health investigations.
• Community of The Good Shepherd may be required by law to disclose to government authorities the medical information of a person who may be a victim of abuse, neglect, or domestic violence.
• Community of The Good Shepherd may disclose your medical information to an agency that oversees government health benefit programs for the purpose of audits, investigations, inspections, or other activities.
• Community of The Good Shepherd may disclose your medical information in response to a court order in a judicial or administrative proceeding, or in some cases, in response to a valid subpoena.
• Community of The Good Shepherd may disclose your medical information to law enforcement officials for a law enforcement purpose in the following situations: when required by law; for identification and location purposes; if you are suspected to be a victim of a crime; to report suspicion of death by criminal conduct; to report suspicion of criminal conduct occurring on the grounds of one of our facilities or your home; and in case of an emergency.
• In the event of your death, Community of The Good Shepherd may disclose your medical information to a coroner, medical examiner or funeral director.
• Your health information may be disclosed to organ donation organizations if you have made arrangements to donate your organs.
• Limited health information may be disclosed if necessary to prevent an immediate threat to the health or safety of the public.
• Your medical information may be disclosed in special government circumstances involving: military or veterans activities; national security and intelligence activities; protective services for the President; medical suitability determinations; law enforcement custodial situations; and government programs providing public benefit.
• Your medical information may be disclosed in accordance with laws related to workers' compensation.
• Community of The Good Shepherd may disclose your medical information to avert a serious threat to your health or safety.
• Community of The Good Shepherd may release medical information about you to your guardian. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family may be notified about your condition, status, and location.
• Community of The Good Shepherd may release your medical information when reporting reactions to medications or problems with products.
• All other uses or disclosures of your medical information will be made only with your (or your guardian's) written authorization. You or your guardian may revoke your written authorization at any time.
• Your Rights:
• The federal law that protects the privacy of your health information gives you several rights:
• You have the right to have a copy of this notice of privacy practices. To obtain a copy of this notice, contact Community of The Good Shepherd at (816) 767-8090.
• You have the right to inspect and copy information in your case record.
• You may also request changes to the information contained in your case record. If you do not agree with what the records say, you can write down what you believe is true and this will be placed in your record also. All requests must be signed and dated.
• You have the right to request that restrictions be placed on the use and disclosure of your health information. Community of The Good Shepherd may approve or deny this request. The Interdisciplinary Team will attempt to explain the advantages and disadvantages of a choice regarding nondisclosure of information. All requests must be in writing, signed and dated and will be placed in the Consumer Record.
• You may also receive a list of uses and disclosures of your health information. Certain limitations may apply.
• You have the right to receive communication from Community of The Good Shepherd about your health information in a confidential manner, and location determined by you.
• You have the right to obtain a copy of all authorizations of release of information.

Grievances:

If you believe that any of these rights or your privacy rights has been violated, you may file a grievance with Community of The Good Shepherd or you may contact the Department of Health and Human Services. You are protected from retaliation for any and all complaints you make. For additional information, or to file a grievance contact the Community of The Good Shepherd privacy and security officer at 816-767-8090, or Health and Human Services as 816-426-3811.

Community of The Good Shepherd Is Obligated To:

• Maintain the privacy of your protected health information.
• bide by the terms of the privacy notice currently in effect.
• Notify you when any changes are made to the privacy notice.

Changes To This Notice:

We have the right to change this notice. We reserve the right 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. We will post a copy of the current notice in the Community of The Good Shepherd administrative office. The notice will contain, on the first page in the top right-hand corner, the effective or revision date. This notice of privacy practices will be reviewed annually and updated/revised whenever there is a material change to the uses or disclosures, your rights, Community of The Good Shepherd's legal duties, or other privacy practices stated in this notice. The revised document will be distributed to and reviewed with all consumers/guardians.

This Notice may be found in: Policy Manual and Consumer Handbook.

Community of The Good Shepherd Notice of Privacy Practices Agreement

I understand as part of my healthcare, Community of The Good Shepherd maintains protected health information (PHI), and medical records in my case record, working files, archive files, etc. These records describe my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the many health professionals who contribute to my care;
• a source of information for applying my diagnosis and protected health information for billing purposes;
• a means by which a third-party payer can verify that services billed were actually provided;
• in addition, a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Privacy Practices, which provides a more complete description of information uses and disclosures. I understand I have the right to review the notice before signing this agreement. I understand that Community of The Good Shepherd reserves the right to change its notice and practices. I may request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that Community of The Good Shepherd is not required to agree to the restrictions requested. I understand I may revoke any written authorization to disclose protected health information in writing, except to the extent that the Community of The Good Shepherd has already released information in accordance with a signed authorization to release protected health information.

Signature of Consumer /Date