Delaware Health & Social Services Division of Services for Aging and Adults with Physical Disabilities NOTICE OF USE OF PRIVATE HEALTH INFORMATION Effective; April 14, 2003 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. IS MY HEALTH INFORMATION PRIVATE? The Division of Services for Aging and Adults with Physical Disabilities provides services to persons with physical disabilities and persons who are aging. To make decisions about services, we need to get private health information from you and sometimes others. Keeping this information private is important to us. The law says: 1. We must keep your health information from others who do not need to know it 2. You may ask that we do not share certain health information. (Sometimes we may not be able to agree with your request.) WHO SEES AND SHARES MY HEALTH INFORMATION? Your private health information may be used by staff' at the Division of Services for Aging and Adults with Physical Disabilities to provide services to you. Unless you tell us in writing to share information with some other person or business, we will only share information for treatment, payment, business operations, or when we are required by law. Treatment - We may give personal medical information about you to coordinate your care. For example, we may tell a home health agency so that it may provide you with proper care. Payment - We may give or get information about you so that care you get can be properly billed and paid for. For example, we may request information from your doctor so that we can pay for certain supplies or equipment for you. Business Operations - We may need to get or share information for our business operations. For example, we may use information to review the quality of care you get. Required by Law - We will give others information when the law says we must. Examples are for law enforcement or national security purposes, subpoenas or other court orders, communicable disease reporting, review of our activities by government agencies, if there is a serious health or safety threat or other emergency. MAY I SEE MY HEALTH INFORMATION? You may see the health information that we have about you. Your requests must be made in writing to the Division. In most cases, you have the right to look at or to get copies of your records. You may be charged a fee for the cost of copying your records. You may ask us to change your records if you think there is a mistake. The law allows us to say no to your request to change your records, but we must give you a reason in writing for saying no. WHAT IF MY HEALTH INFORMATION NEEDS TO GO SOMEWHERE ELSE? You may be asked to sign a separate form, called a Health Information Authorization Form, allowing your health care information to go somewhere else if: 1. Your health care provider needs to send it to other places; 2. You want us to send it to another health care provider; or 3. You want it sent to another person. This authorization form tells us what, where and to whom the information must be sent, Your authorization is good for six (6) months or until the date you put on the form. You may change your mind and cancel your permission. But you must do this in writing. DO I HAVE ANY OTHER PRIVACY RIGHTS? In addition to being able to review you health records and to make corrections, you have the following rights: 1. Right to a list of disclosures - You have the right to ask for a list of disclosures or names of people or agencies we have shared information with after April 14, 2003. This list will not include information disclosed for treatment, payment or business operations. It will not include information provided directly to you or information that was sent with your authorization. 2. Right to request limits on how we use or disclose information about you - You have the right to ask for limits on how your information is used. We are not required to agree to such requests. 3. Right to request confidential communications - You have the right to ask that we share information with you in a certain way or in a certain place. For example, you may ask us to send information to you at your work address instead of your home address. You do not have to explain the reason for your request. 4. Right to receive a paper copy of this notice - This notice is yours. If you need another copy, you may ask for one by calling our toll free number (800) 223-9074 or you may print one from our website http://www.dhss.delaware.gov/dsaapd/ . HOW CAN I FIND OUT IF MY HEALTH INFORMATION HAS BEEN RELEASED? To find out if your health information has been released without your authorization for purposes other than treatment, payment or business operations, you may call the Division of Services for Aging and Adults with Physical Disabilities toll-free at (800) 223-9074. CAN THIS NOTICE BE CHANGED? The Division of Services for Aging and Adults with Physical Disabilities reserves the right to revise this notice. A revised notice will be effective for information we already have about you as well as any information we may receive in the future. We are required by law to follow whatever notice is currently in effect. Any changes to our notice will be published on our website http://www.dhss.delaware.gov/dsaapd/ . WHAT IF I HAVE QUESTIONS OR WANT TO FILE A COMPLAINT? If you have any questions about this notice, or you think that we have not protected your private health information and you wish to complain about it, please contact the Complaint Officer at: Division of Services for Aging and Adults with Physical Disabilities Main Building, 1901 N. DuPont Highway, New Castle, DE 19720 (800) 223-9074 Or contact Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Washington, DC 20201-0004 (800) 368-1010 WHAT WILL HAPPEN TO MY SERVICES? Nothing will happen to your services if you file a complaint. Benefits are NOT affected because you file a complaint. It is against the law for us to take any action against you if you do file a complaint. Delaware Health & Social Services Division of Services for Aging and Adults with Physical Disabilities NOTICE OF USE OF PRIVATE HEALTH INFORMATION I _______________________________have been given a copy of the DHSS Division of Services (Client name) for Aging and Adults with Physical Disabilities’ NOTICE OF USE OF PRIVATE HEALTH INFORMATION. Client Signature:_____________________________________________Date: _____________________ Revised 1/7/08