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. 

The Aging and Disability Services Division (hereafter the Division) uses health information about you to provide services, to obtain payment for services, for administrative purposes, and to evaluate the quality of care that you receive.  Your health information is contained in a file that is the physical property of the Division. 

How the Division May Use or Disclose Your Health Information 

For Service:  The Division may use your health information to provide services to you.  For example, the Division staff or other person providing services to you will record information related to your service.  This information is necessary for providers to determine what services you should receive.  Providers will also enter actions taken by them in the course of your service and note how you respond to the actions. 

For Payment:  The Division may use and disclose your health information to others for purposes of receiving payment for services you receive.  For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan.  The information on the bill may contain information that identifies you, your diagnosis, and service or supplies used in the course of service. 

For Operations:  The Division may use and disclose health information about you for operational purposes.  For example, your health information may be disclosed to staff members, risk or quality improvement personnel, and others to:

·     evaluate the performance of our staff;

·     assess the quality of services and outcomes in your case and similar cases;

·     learn how to improve our services; and

·     determine how to continually improve the quality and effectiveness of the services we provide. 

Emergency Treatment:  Even if an individual has requested additional restrictions on uses and disclosures of health information and the Division has agreed, if the individual is in need of emergency treatment and the restricted protected health information is needed to give the emergency treatment, the Division may use the restricted protected health information, or may disclose such information to a health care provider, to give such treatment to the individual.  The Division will require that such health care provider not further use or disclose the information. 

Appointments:   The Division may use your information to contact you about appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Personal Representative:  Health information may be disclosed to an individual’s personal representative if the person is authorized to act on behalf of an individual, or under the law the person is an executer, administrator or other person with authority to act on behalf of a 
deceased individual.

Required by Law:  The Division may use and disclose information about you as required by law. For example, the Division may disclose information for the following purposes:

·        for judicial and administrative proceedings pursuant to legal authority;

·        to report information related to victims of abuse, neglect or domestic violence; and

·        to assist law enforcement officials in their law enforcement duties; 

Public Health:  Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities. 

Decedents: Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties. 

Research:  The Division may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research. 

Health and Safety:  Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law. 

Government Functions:  Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services. 

Workers’ Compensation:  Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation. 

Other uses:  Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent the Division has taken action in reliance on such. 

Your Health Information Rights 

 You have the right to:

·     Request a restriction on certain uses and disclosures of your health information; however, the Division is not required to agree to a requested restriction;

·     Obtain a paper copy of the notice of information practices upon request;

·     Inspect and obtain a copy of your file;

·     Request that your file be amended or corrected;

·     Request communications of your health information by alternative means or at alternative locations; and

·     Receive an accounting of disclosures made of your health information. 

Complaints

You may complain to the Division and to the Department of Health and Human Services if you believe your privacy rights have been violated.  You will not be retaliated against for filing a complaint. 

Obligations of the Division

The Division is required by law to:

·     Maintain the privacy of protected health information;

·     Provide you with this Notice of its legal duties and privacy practices with respect to your health information;

·     Abide by the terms of this Notice;

·     Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;

·     Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and 

The Division reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains.  Revised Notices will be made available to you upon request.

 

Contact Information

If you have any questions or complaints, please contact us at:           

Aging and Disability Services Division
            3416 Goni Road, Building D, Suite 132
            Carson City, Nevada  89706
            Phone:  775-687-4210 

Or you may contact the Department of Health and Human Services at: 

            Office for Civil Rights
            U.S. Department of Health and Human Services
            200 Independence Avenue, S.W.
            Room 509F, HHH Building
            Washington, D.C. 20201
            Phone:  OCR Hotlines-Voice: 1-800-368-1019  

 

ACKNOWLEDGEMENT OF RECEIPT OF THE DIVISION
NOTICE OF PRIVACY PRACTICES 

By signing this document, I acknowledge that I have received a copy of the Division Notice of Privacy Practices.

Name (Print): _________________________________  Signature: _____________________________________

Date: ___________________