Summary of Agency's Notice of Privacy Practices

This notice briefly describes how medical information about you may be used and disclosed and how you can get a copy of this information. This is intended to summarize for you the longer, more detailed form of notice following. You should review both carefully.

At Gardner V.N.A., your privacy is a priority. We follow federal and state guidelines, whichever is stricter, to maintain the confidentiality of your medical information. We use your medical information to provide you home care services, to obtain payment for our services, and to conduct our business, known as health care operations.

We may also use information to tell you about health benefits and services, to communicate with other health care providers, family or friends involved in your care, and to communicate with associates who carry out treatment, payment, or health care operations on our behalf. These associates must follow our strict privacy rules. We may also contact you for Agency fundraising, but you can always tell us not to do so.

There are limited times when we are permitted or required to disclose medical information without your signed permission. These situations include public health activities, if required by law, and for specialized government functions. Other uses and disclosures in this category are listed in the attached log form of notice. All other uses and disclosures may only be done with your signed authorization. You may revoke your authorization at any time.

You have the right to request that we restrict how we use or disclose your medical information. We may not be able to comply with all requests. You also have the right to tell us how you want us to contact you, to see and copy your medial information and to request additions or corrections, and receive an accounting of how we disclosed your information, except for our payment, treatment and operations, which does not require such an accounting.

To obtain more information, or if you have a complaint or concern regarding the use of your information, call or write our privacy officer. The contact information is listed in the following Notice. All complaints will be thoroughly investigated. You may also file a complaint with the Secretary of Health and Human Services in Washington, D.C.

NOTICE OF PRIVACY PRACTICE

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 of Privacy Practices describes how Gardner V.N.A. may use and disclose your protected health information to carry out your plan of care, get paid for our services, administer Gardner V.N.A. and for other purposes that are permitted or required by law.

This Notice also describes your rights with respect to your health information.

Our Responsibilities We are required by law to protect the privacy of your health information and will not use or disclose your health information without your written permission, except as described in this Notice. If we change our practices and this Notice, we will give you a revised Notice.

Throughout this Notice, we use the term “protected health information" or PHI. PHI is information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

You Have a Right to: · Request that we limit certain uses and disclosures of your information. You have the right to request that we limit how we use or disclose your PHI to carry out your plan of care, get paid for our services or administer Gardner V.N.A.. (This is also referred to as “treatment, payment, or health care operations.") You also have the right to request a restriction on the PHI we disclose about you to someone who is involved in your care or payment for your care, such as a family member or friend. However, we are not required to agree to your request. To request limitations or restrictions, you must send a written request to:

Gardner V.N.A.
Attn: Privacy Officer
34 Pearly Lane
Gardner Ma. 01440.

See and get a copy of your information. You have the right to look at and copy PHI about you contained in your medical and billing records for as long as Gardner V.N.A. maintains the information. To look at or copy your PHI, please send a written request to the above address. If you request a copy of the information, we may charge you a fee for the costs of the copying, mailing, or other supplies that are necessary to grant your request. We may deny your request in certain limited circumstances. If you are denied the right to see or copy your PHI, you may request that the denial be reviewed.

Correct or update your information. If you feel that PHI Gardner V.N.A. has about you is incomplete or incorrect, you may request that Gardner V.N.A. correct or update (amend) the information. You may request an amendment for as long as Gardner V.N.A. maintains your health information. To request an amendment, you must send a written request to the above address. In addition, you must include the reasons for your request. In certain cases, Gardner V.N.A. may deny your request for amendment. If Gardner V.N.A. denies your request for amendment, you have the right to file a statement of disagreement with the decision and Gardner V.N.A. may prepare a response to your statement, which will be provided to you.

Receive a list of the disclosures of your information. You have the right to receive a list (“accounting") of the disclosures we have made of your PHI for most purposes other than treatment, payment, or health care operations. The accounting will not include disclosures Gardner V.N.A. has made directly to you, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other limitations. To request an accounting, you must submit your request in writing to the above address­. Your request must state the time period, but may not be longer than six years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. Gardner V.N.A. will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

Request communications of your information by alternative means or at alternative locations. For instance, you may request that we contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of your PHI, you must submit your request in writing to the above address. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.

Withdraw your consent to use or disclose PHI except to the extent that action has already been taken. You may withdraw or “revoke" a consent in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the consent. Gardner V.N.A. may refuse to continue to treat an individual that revokes his or her consent.

Obtain a paper copy of the Notice of Privacy Practices upon request. You may request a copy of the Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy of the Notice. To obtain a paper copy of the Notice, contact Medical records at the above address.

Using and Disclosing Your Protected Health Information We will use your information for your care and treatment. For example, information obtained by a nurse or other member of your care team will be recorded in your record and used to determine your plan of care. Your clinician will document in your record his or her expectations of the members of your care team. Members of your healthcare team will then record the actions they took and their observations.

We will use your information for payment. For example, a bill may be sent to you, your insurance company or Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as the treatment provided to you.

We will use your protected health information to operate Gardner VNA. For example, members of our quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.

We may use or disclose your PHI without your consent in the following circumstances: · When a disclosure is required by federal, state or local law, judicial or administrative proceedings or law enforcement: For example, Gardner V.N.A. may disclose your PHI for law enforcement purposes as required by law or in response to a valid subpoena. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. Gardner V.N.A. may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Before using or disclosing your PHI for any other purposes, Gardner V.N.A. will obtain your written authorization. You may withdraw or “revoke" this authorization in writing at any time. After Gardner V.N.A. receives your written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

For More Information or to Report a Problem If you have questions or would like additional information about Gardner V.N.A.'s privacy practices, you may contact the Privacy Officer, GVNA, 34 Pearly Lane, Gardner Massachusetts 01440. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

This Notice is Effective as of April 14, 2003. Acknowledgement of Receipt of this Notice Please sign below indicating that you have received a copy of this Notice __________ ____________________________________ ______________________________

Signature of Client or Personal Representative Date

 

Client's Name

 

Personal Representative's Name Relationship to Client

Notice Of Privacy Practices

Please sign below indicating that you have received a copy of this Notice_______________ ____________________________________ ______________________________

Signature of Client or Personal Representative Date

Client's Name

Personal Representative's Name Relationship to Client