PRIVACY POLICY

PRIVACY ACT STATEMENT - HEALTH CARE RECORDS

THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974).

THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USEDTO RELEASE OR TOUSE YOUR HEALTH CARE INFORMATION.

I. AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER,

AND WHETHER OR NOT YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THIS ASSESSMENT. Sections 1102(a), 1154,1861(0), 1861(z), 1863, 1864, 1865, 1866, 1871, 1891(b) of the Social Security Act.

Medicare and Medicaid participating home health agencies must do a complete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the "Outcome and Assessment Information Set" (OASIS) when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Centers for Medicare & Medicaid Services (CMS, the federal Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate healthcare to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the federal Privacy Act of 1974 and the "Home Health Agency Outcome and Assessment Information Set" (HHA OASIS) System of Records. You have the right to see, copy, review, and request correction of your information in the HHA OASIS System of Records.

 

II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED

The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-70-9002.

Your health care information in the HHA OASIS System of Records will be used for the following purposes:

• support litigation involving the Centers for Medicare & Medicaid Services;

• support regulatory, reimbursement, and policy functions performed within the Centers for Medicare &Medicaid Services or by a contractor or

consultant;

• study the effectiveness and quality of care provided by those home health agencies;

• survey and certification of Medicare and Medicaid home health agencies;

• provide for development and refinement of a Medicare prospective payment system;

• enable regulators to provide home health agencies with data for their internal quality improvement activities;

• support research, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restoration or

maintenance of health, and for health care payment related projects; and

• support constituent requests made to a Congressional representative.

Ill . ROUTINE USES

These "routine uses" specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the HHA OASIS System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information.

Disclosures of the information may be to:

1. the federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services;

2. contractors or consultants working for the Centers for Medicare & Medicaid Services to assist in the performance of a service

related to this system of records and who need to access these records to perform the activity;

3. an agency of a State government for purposes of determining, evaluating and/or assessing cost, effectiveness, sand/or quality of

healthcare services provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of

Federal/State home health agency programs within the State;

4. another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services' health insurance operation ns (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by

HHAs;

5. Quality Improvement Organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health agency quality of care;

6. an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the

restoration maintenance of health, or payment related projects;

7. a congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained.

IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION

The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services.

NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your representative to sign this statement to document that this statement was given to you. Your signature is NOT required. If you or your representative sign the statement the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement.

CONTACT INFORMATION

If you want to ask the Centers for Medicare and Medicaid Services to see, review, copy, or correct your personal health information that the Federal agency maintains in its HHA OASIS System of Records:

Call 1-800-MEDICARE, toll free, for assistance in contacting the HHA OASIS System Manager.

TTY for the hearing and speech impaired: 1-877-486-2048

Care in the Home Health Services

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.

Respite Care/Care in the Home, lnc./dba/Care in the Home Health Services (Agency) is committed to maintaining the confidentiality of all information it receives. The purpose of this notice is to inform you of how Agency may use and disclose Protected Health Information (PHI). Agency is required by law to maintain the privacy of PHI and to provide all individuals served with notice of Agency's legal duties and privacy practices with respect to PHI. Agency will abide by the terms set forth in this Notice.

 

HOW WE USE OR DISCLOSE YOUR MEDICAL INFORMATION- Without separate consent or authorization

1. Treatment - Agency will use medical information about you to provide you with home care services and treatment. For example, information may be shared with members of our staff, your doctors, or any health care or assisted living or personal care facilities to which you are admitted.

2. Payment - Agency is normally required to disclose your medical information to: obtain prior approval from an insurer before providing services to you; bill and collect payment for services we provided you.

3. Health Care Operations - Agency may use or disclose your medical information for quality improvement, staff evaluation, or other operational purposes. Your name and address may be used to send out satisfaction surveys, or we may call you to remind you that our staff will be visiting you. We have business associates such as accountants, consultants and attorneys that provide some services for us. We have a written contract with them that requires them to protect the privacy of your medical information. Licensing and accrediting bodies and surveyors may also have access to your medical information when they are evaluating the quality of our services.

4. Health Related Benefits, Services and Treatment Alternatives - Agency may use and disclose medical information about you to contact you about other health related benefits, services or treatments that may be available to you. If you do not want to receive these communications, please notify Our Designee in writing.

5. Individuals Involved in Your Care - Agency may disclose medical information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may disclose medical information about you if they need to be notified of your location, general condition or death. Please advise us if there is someone living in your home, a close friend or a caregiver that you do not want us to share information with, or if you do not want us to leave any messages on your telephone answering machine.

6. Uses or Disclosures That Are Required or Permitted by Law -

Agency may use or disclose medical information about you as necessary as required by law and for the following reasons: OASIS data transmission as required for government medical payments, emergency care, disaster relief efforts; public health activities to report, prevent or control diseases; research under certain limited circumstances; reporting of abuse, neglect or domestic violence; health oversight agencies, to Food and Drug Administration to monitor drugs/devices; to the police or law enforcement officials as required by law or in compliance with a court order or other process authorized by law, to units of the government with special functions, such as the U.S. Military or the U.S. Dept. of State, and to prevent a threat to public health or safety, funeral directors, coroners and medical examiners; organ donation; Workers' Compensation to provide benefits for work-related injuries or illnesses. When substantial barriers to communicating with you exist and we determine that consent is clearly inferred from the circumstances.

Uses or Disclosures That Require Your Authorization

Other uses and disclosures will be made only with your, written authorization, which you may cancel at any time by notifying Our Designee in writing of your desire to cancel it. Examples of this type of disclosure would include: Drug companies request for your information for marketing purposes, or an attorney requesting your medical information for use in a civil law suit.

YOUR RIGHTS

The information contained in your health, or medical record is the physical property of Agency. The information in it belongs to you. You have the following rights:

1. Right to Request Restrictions - You have the right to ask us not to use/disclose your medical information for a particular reason related to treatment, payment or our operations. You have the right to withhold information from your health plan on services paid out of pocket. You may ask that family members or other individuals not be informed of specific medical information. Requests must be made in writing to Our Designee. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. Either you or Agency can stop a restriction at any time.

2. Right to Receive Confidential Communications - You have the right to ask that we communicate with you in a certain manner or at a certain place. A request for confidential communications must be made in writing to Our Designee. We must agree with the request, if it is reasonable.

3. Right to Inspect and Copy Your Medical Information - You have the right to request, inspect, and obtain a copy of your paper or electronic PHI. You must submit a request in writing to Our Designee. We may charge a fee for the costs of copying, summarizing and/or mailing information to you. If we agree to your request, we will tell you. We may deny your request under certain limited

circumstances, and we will let you know in writing, if your request is denied. You may be able to request a review of our denial.

 

4. Right to Request Amendments to Your Medical Information - You have the right to request that we correct your medical information. You must submit your request for an amendment in writing to Our Designee, if you believe that any medical information in your record is incorrect or that important information is missing. We do not have to agree to your request. If we deny your request, we will tell you why. You have the right to submit a statement disagreeing with our decision. We may deny a request if we determine that the information: 1. Was not created by us, 2. Is not part of the medical information that we maintain 3. Is in records that you are not allowed to inspect and copy, and 4. Current medical information.nation is already accurate and complete.

5. Right To An Accounting of Disclosures of Health Information - You have a right to find out what disclosures of your PHI have been made by the Agency/Business Associates. The list of disclosures - an accounting, may be made for up to three (3) years prior to the date on which you request the accounting, but cannot include disclosures before April 14, 2003. We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. You are entitled to one free accounting in any twelve (12) month period and must submit a written request to Our Designee. We may charge you for the cost of providing additional accountings. We will notify you in advance if there is an additional charge.

6. Right To Obtain a Copy of the Notice - The effective date of this notice is January 8, 2018. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information that we maintain. We will promptly notify you with a revised notice as soon as practical, if we change the terms of this notice, while you are receiving services from us.

7. Right to Notification of a Breach of unsecure data within 60 days following discovery by the Agency.

Questions/Complaints - If you believe that your privacy rights have been violated, you may contact Respite Care/Care in the Home, Inc. directly or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for reporting a violation of your privacy rights. If you have any questions; want more information, or wish to file a complaint with us, please contact

by phone, or by mail:

HealthCare Privacy Officer/Administrator 1200 Central Ave., Wilmette, IL 60091

Tel: (847) 256-1705 Fax (847) 512-0962

chhs@careinthehome.com

CARE IN THE HOME WISCONSIN 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.

Respite Care/Care in the Home, Inc./dba/Care in the Home Wisconsin (Agency) is committed to maintaining the confidentiality of all information it receives. The purpose of this notice is to inform you of how Agency may use and disclose Protected Health Information (PHI). Agency is required by law to maintain the privacy of PHI and to provide all individuals served with notice of Agency's legal duties and privacy practices with respect to PHI. Agency will abide by the terms set forth in this Notice.

HOW WE USE OR DISCLOSE YOUR MEDICAL INFORMATION - Without separate authorization

1. Treatment -Agency will use medical information about you to provide you with home care services and treatment. For example, information may be shared with members of our staff, your doctors, or health care facilities.

2. Payment -Agency is normally required to disclose your medical information to: obtain prior approval from an insurer before providing services to you; bill and collect payment for services we provided you.

3. Health Care Operations - Agency may use or disclose your medical information for quality improvement, staff

evaluation, or other operational purposes. Your name and address may be used to send out satisfaction surveys, or we

may call you to remind you that our staff will be visiting you. We have business associates such as accountants,

consultants and attorneys that provide some services for us. We have a written contract with them that requires them to

protect the privacy of your medical information. Government surveyors may also have access to your medical

information when they are evaluating the quality of our services.

4. Health Related Benefits, Services and Treatment Alternatives - Agency may use and disclose medical information about you to contact you about other health related benefits, services or treatments that may be available to you. If you do not want to receive these communications, please notify Our Designee in writing.

5. Individuals Involved in Your Care - Agency may disclose medical information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may disclose medical information about you if they need to be notified of your location, general condition or death. Please advise us if there is someone living in your home, a close friend or a caregiver that you do not want us to share information with, or if you do not want us to leave any messages on your telephone answering machine.

6. Uses or Disclosures That Are Required or Permitted by Law - Agency may use or disclose medical information about you as necessary as required by law and for the following reasons: Disaster relief efforts; public health activities to report, prevent or control diseases; research under certain limited circumstances; reporting of abuse, neglect or domestic violence; health oversight agencies, to Food and Drug Administration to monitor drugs/devices; to the police or law enforcement officials as required by law or in compliance with a court order or other process authorized by law, to units of the government with special functions, such as the U.S. Military or the U.S. Dept. of State, and to prevent a threat to public health or safety, funeral directors, coroners and medical examiners; organ donation; Workers' Compensation to provide benefits for work-related injuries or illnesses.

USES OR DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other uses and disclosures will be made only with your written authorization, which you may cancel at any time by notifying Our Designee in writing of your desire to cancel it. Examples of this type of disclosure would include: Drug companies request for your information for marketing purposes, or an attorney requesting your medical information for use in a civil law suit.

YOUR RIGHTS

The information contained in your health, or medical record is the physical property of Agency. The information in it belongs to you. You have the following rights:

1. Right to Request Restrictions - You have the right to ask us not to use/disclose your medical information for a particular reason related to treatment, payment or our operations. You have the right to withhold information from your health plan on services paid out of pocket. You may ask that family members or other individuals not be informed of specific medical information. Requests must be made in writing to Our Designee. We do not have to agree to your request. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. Either you or Agency can stop a restriction at any time.

2. Right to Receive Confidential Communications - You have the right to ask that we communicate with you in a certain manner or at a certain place. A request for confidential communications must be made in writing to Our Designee. We must agree with the request, if it is reasonable.

3. Right to Inspect and Copy Your Medical Information - You have the right to request, inspect, and obtain a copy of your paper or electronic PHI. You must submit a request in writing to Our Designee. We may charge a fee for the costs of copying, summarizing and/or mailing information to you. If we agree to your request, we will tell you. We may deny your request under certain limited

circumstances, and we will let you know in writing, if your request is denied. You may be able to request a review of our denial.

 

4. Right to Request Amendments to Your Medical Information - You have the right to request that we correct your medical information. You must submit your request for an amendment in writing to Our Designee, if you believe that any medical information in your record is incorrect or that important information is missing. We do not have to agree to your request. If we deny your request, we will tell you why. You have the right to submit a statement disagreeing with our decision. We may deny a request if we determine that the information: 1. Was not created by us, 2. Is not part of the medical information that we maintain 3. Is in records that you are not allowed to inspect and copy, and 4. Current medical information.nation is already accurate and complete.

5. Right To An Accounting of Disclosures of Health Information - You have a right to find out what disclosures of your PHI have been made by the Agency/Business Associates. The list of disclosures - an accounting, may be made for up to three (3) years prior to the date on which you request the accounting, but cannot include disclosures before April 14, 2003. We are not required to include disclosures for treatment, payment or healthcare operations or certain other exceptions. You are entitled to one free accounting in any twelve (12) month period and must submit a written request to Our Designee. We may charge you for the cost of providing additional accountings. We will notify you in advance if there is an additional charge.

6. Right To Obtain a Copy of the Notice - The effective date of this notice is January 8, 2018. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information that we maintain. We will promptly notify you with a revised notice as soon as practical, if we change the terms of this notice, while you are receiving services from us.

7. Right to Notification of a Breach of unsecure data within 60 days following discovery by the Agency.

Questions/Complaints - If you believe that your privacy rights have been violated, you may contact Respite Care/Care in the Home, Inc. directly or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for reporting a violation of your privacy rights. If you have any questions; want more information, or wish to file a complaint with us, please contact

by phone, or by mail:

HealthCare Privacy Officer

10505 Corporate Drive, Suite 102, Pleasant Prairie, WI 53158.

Tel: (262) 857-3050 Fax (262) 857-2688

 

12/10/2015