NOTICE OF
PRIVACY PRACTICES
(45 CFR §164.520(a))
Consumer Name: ____________________________________ Effective Date:
__________
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.
If you have any questions about this notice, please contact the Privacy
Officer.
WHO WILL FOLLOW THIS NOTICE.
This notice describes our practices and that of:
* Any health care professional authorized to enter information into your
chart.
* All departments and units of Forte Residential, Inc.,.
* Any member of a volunteer group we allow to help you at Forte
Residential, Inc.,.
* All employees, staff and other personnel of Forte Residential, Inc.,.
* All these entities, sites and locations follow the terms of this
notice. In addition, these entities, sites and locations may share
medical information with each other for treatment, payment or Forte
Residential, Inc., operations purposes described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION.
We understand that medical information about you and your health is
personal. We are committed to protecting medical information about you.
We create a record of the care and services you receive at Forte
Residential, Inc.,. We need this record to provide you with quality care
and to comply with certain legal requirements. This notice applies to
all of the records of your care generated by Forte Residential, Inc.,.
Other Health Care Rehabilitation Facilities may have different policies
or notices regarding use and disclosure of your medical information.
This notice will tell you about the ways in which we may use and
disclose medical information about you. We also describe your rights and
certain obligations we have regarding the use and disclosure of medical
information.
We are required by law to:
* make sure that medical information that identifies you is kept
private;
* give you this notice of our legal duties and privacy practices with
respect to medical information about you; and
* follow the terms of the notice that is currently in effect.
HOW WE ARE REQUIRED BY LAW TO DISCLOSE MEDICAL INFORMATION ABOUT YOU.
* As Required By Law. We will disclose medical information
about you when required to do so by federal, state or local law.
* To Avert a Serious Threat to Health or Safety. We will
use and disclose medical information about you when we have a “Duty to
Report” under state or federal law, because we believe that it is
necessary to prevent a serious threat to your health and safety or the
health and safety of the public or another person. Any disclosure,
however, would only be to someone able to help prevent the threat.
* Public Health Risks. We will disclose medical
information about you for public health reporting required by federal or
state law. These activities generally include the following:
* to prevent or control disease, injury or disability;
* to report births and deaths;
* to report child abuse or neglect;
* to report reactions to medications or problems with products;
* to notify people of recalls of products they may be using;
* to notify a person who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition;
* to notify the appropriate government authority if we believe a
Consumer has been the victim of abuse, neglect or domestic violence. We
will only make this disclosure if you agree or when required or
authorized by law.
* Health Oversight Activities. We will disclose medical
information as required by law to a health oversight agency for
activities authorized by law. These oversight activities include, for
example, audits, investigations, inspections, and licensure. These
activities are necessary for the government to monitor the health care
system, government programs, and compliance with civil rights laws.
* Lawsuits and Disputes. If you are involved in a lawsuit
or a dispute, we will disclose medical information about you when
properly ordered to do so by a court.
* Law Enforcement. We will release medical information if
asked to do so by a law enforcement official, and if permitted by law:
* In response to a court order;
* If required by state or federal law;
* To identify or locate a suspect, fugitive, material witness, or
missing person;
* About the victim of a crime if, under certain limited circumstances,
we are unable to obtain the person's agreement;
* About a death we believe may be the result of criminal conduct;
* About criminal conduct at a Forte Residential, Inc., facility; and
* In emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the person
who committed the crime.
* Protective Services for the President and Others. We
will disclose medical information about you to authorized federal
officials so they may provide protection to the President, other
authorized persons or foreign heads of state or conduct special
investigations.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and
disclose medical information. For each category of uses or disclosures
we will explain what we mean and try to give some examples. Not every
use or disclosure in a category will be listed. However, all of the ways
we are permitted to use and disclose information will fall within one of
the categories.
* For Treatment. We may use medical information about you to
provide you with medical treatment or services. We may disclose medical
information about you to doctors, psychologists, nurses, social workers,
therapists, technicians, medical students, or other Forte Residential,
Inc., personnel who are involved in taking care of you. Different
departments of the Forte Residential, Inc., also may share medical
information about you in order to coordinate the different things you
need. We also may disclose medical information about you to people
outside Forte Residential, Inc.,, such as other health care providers
involved in providing medical treatment for you and to people who may be
involved in your medical care, such as family members, clergy or others
we use to provide services that are part of your care.
* For Payment. We may use and disclose medical information
about you so that the treatment and services you receive at Forte
Residential, Inc.,, or other health care providers from whom you receive
treatment, may be billed to, and payment may be collected from, you, an
insurance company or a third party. For example, we may need to give
your health plan information about treatment you received at Forte
Residential, Inc., so your health plan will pay us or reimburse you for
your treatment. We may also tell your health plan about a treatment you
are going to receive to obtain prior approval or to determine whether
your plan will cover the treatment.
* For Health Care Operations. We may use and disclose
medical information about you for Forte Residential, Inc., operations or
to another health care provider or health plan, if you have a
relationship with that health care provider or health plan . These uses
and disclosures are necessary to run Forte Residential, Inc., and make
sure that all of our Consumers receive quality care. For example, we may
use medical information to review our treatment and services and to
evaluate the performance of our staff in caring for you. We may also
combine medical information about many Consumers to decide what
additional services Forte Residential, Inc., should offer, what services
are not needed, and whether certain new treatments are effective. We may
also disclose information to doctors, social workers, therapists,
nurses, psychologists, technicians, medical students, and other
personnel for review and learning purposes. We may also combine the
medical information we have with medical information from other Health
Care Rehabilitation Facilities to compare how we are doing and see where
we can make improvements in the care and services we offer. We may
remove information that identifies you from this set of medical
information so others may use it to study health care and health care
delivery without learning who the specific Consumers are.
* Appointment Reminders. We may use and disclose medical
information to contact you as a reminder that you have an appointment
for treatment or medical care at Forte Residential, Inc.,.
* Treatment Alternatives. We may use and disclose medical
information to tell you about or recommend possible treatment options or
alternatives that may be of interest to you.
* Health-Related Benefits and Services. We may use and
disclose medical information to tell you about health-related benefits
or services that may be of interest to you.
* Fundraising Activities. Forte Residential, Inc., does
not use Consumer information for fundraising purposes.
* Facility Directory. We may include certain limited
information about you in a facility directory while you are a Consumer
at a Forte Residential, Inc., facility. This information may include
your name, location, your general condition (e.g., fair, stable, etc.)
and your religious affiliation. The directory information, except for
your religious affiliation, may also be released to people who ask for
you by name. Your religious affiliation may be given to a member of the
clergy, such as a priest or rabbi, even if they don't ask for you by
name. This is so your family, friends and clergy can visit you at the
facility and generally know how you are doing.
* Individuals Involved in Your Care or Payment for Your Care.
We may release certain limited information about you to a friend or
family member who is involved in your medical care. We may also give
information to someone who helps pay for your care. We may also tell
your family or friends your condition. In addition, we may disclose
medical information about you to an entity assisting in a disaster
relief effort so that your family can be notified about your condition,
status and location.
* Research. Under certain circumstances, we may use and
disclose medical information about you for research purposes. For
example, a research project may involve comparing the health and
recovery of all Consumers who received one medication to those who
received another, for the same condition. All research projects,
however, are subject to a special approval process. This process
evaluates a proposed research project and its use of medical
information, trying to balance the research needs with Consumers' need
for privacy of their medical information. Before we use or disclose
medical information for research, the project will have been approved
through this research approval process, but we may, however, disclose
medical information about you to people preparing to conduct a research
project, for example, to help them look for Consumers with specific
medical needs, so long as the medical information they review does not
leave Forte Residential, Inc.,. We may ask for your specific permission
if the researcher will have access to your name, address or other
information that reveals who you are, or will be involved in your care
at the hospital.
SPECIAL SITUATIONS
* Organ and Tissue Donation. If you are an organ donor, we
may release medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
* Military and Veterans. If you are a member of the armed
forces, we may release medical information about you as required by
military command authorities. We may also release medical information
about foreign military personnel to the appropriate foreign military
authority.
* Coroners, Medical Examiners and Funeral Directors. We
may release medical information to a coroner or medical examiner. This
may be necessary, for example, to identify a deceased person or
determine the cause of death. We may also release medical information
about Consumers of Forte Residential, Inc., to funeral directors as
necessary to carry out their duties.
* National Security and Intelligence Activities. We may
release medical information about you to authorized federal officials
for intelligence, counterintelligence, and other national security
activities authorized by law.
* Inmates. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may
release medical information about you to the correctional institution or
law enforcement official. This release would be necessary (1) for the
institution to provide you with health care; (2) to protect your health
and safety or the health and safety of others; or (3) for the safety and
security of the correctional institution.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.
You have the following rights regarding medical information we maintain
about you:
* Right to Inspect and Copy. You have the right to inspect
and copy medical information that may be used to make decisions about
your care. Usually, this includes medical and billing records, but does
not include psychotherapy notes.
To inspect and copy medical information that may be used to make
decisions about you, you must submit your request in writing to The
Privacy Officer. If you request a copy of the information, we may charge
a fee for the costs of copying, mailing or other supplies associated
with your request.
We may deny your request to inspect and copy in certain very limited
circumstances. If you are denied access to medical information, under
some circumstances you may request that the denial be reviewed. Another
licensed health care professional chosen by Forte Residential, Inc.,
will review your request and the denial. The person conducting the
review will not be the person who denied your request. We will comply
with the outcome of the review.
* Right to Amend. If you feel that medical information we have
about you is incorrect or incomplete, you may ask us to amend the
information. You have the right to request an amendment for as long as
the information is kept by or for Forte Residential, Inc.,.
To request an amendment, your request must be made in writing and
submitted to The Privacy Officer. In addition, you must provide a reason
that supports your request.
We may deny your request for an amendment if it is not in writing or
does not include a reason to support the request. In addition, we may
deny your request if you ask us to amend information that:
* Was not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
* Is not part of the medical information kept by or for the hospital;
* Is not part of the information which you would be permitted to inspect
and copy; or
* Is accurate and complete.
* Right to an Accounting of Disclosures. You have the right to request
an "Accounting of Disclosures." This is a list of the disclosures we
made of medical information about you.
To request this list or accounting of disclosures, you must submit your
request in writing to The Privacy Officer. Your request must state a
time period which may not be longer than six years and may not include
dates before April 1, 2003. Your request should indicate in what form
you want the list (for example, on paper, electronically). The first
list you request within a 12 month period will be free. For additional
lists, we may charge you for the costs of providing the list. We will
notify you of the cost involved and you may choose to withdraw or modify
your request at that time before any costs are incurred.
* Right to Request Restrictions. You have the right to
request a restriction or limitation on the medical information we use or
disclose about you for treatment, payment or health care operations. You
also have the right to request a limit on the medical information we
disclose about you to someone who is involved in your care or the
payment for your care, like a family member or friend. For example, you
could ask that we not use or disclose information about a specific
treatment session you had.
We are not required to agree to your request. If we do agree, we will
comply with your request unless the information is needed to provide you
emergency treatment.
To request restrictions, you must make your request in writing to The
Privacy Officer. In your request, you must tell us (1) what information
you want to limit; (2) whether you want to limit our use, disclosure or
both; and (3) to whom you want the limits to apply, for example,
disclosures to your spouse.
* Right to Request Confidential Communications. You have
the right to request that we communicate with you about medical matters
in a certain way or at a certain location. For example, you can ask that
we only contact you at work or by mail.
To request confidential communications, you must make your request in
writing to The Privacy Officer. We will not ask you the reason for your
request. We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
* Right to a Paper Copy of This Notice. You have the right
to a paper copy of this notice. You may ask us to give you a copy of
this notice at any time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, contact the Office Manager.
CHANGES TO THIS NOTICE
* We reserve 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 each of our
facilities. The notice will contain on the first page, in the top
right-hand corner, the effective date. In addition, each time you
register at or are admitted to Forte Residential, Inc., for treatment or
health care services as an inpatient or outpatient, we will offer you a
copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a
complaint with Forte Residential, Inc., or with the Secretary of the
Department of Health and Human Services. To file a complaint with Forte
Residential, Inc.,, contact Tom Van Meter, President, 574.528-6398. All
complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this
notice or the laws that apply to us will be made only with your written
permission. If you provide us permission to use or disclose medical
information about you, you may revoke that permission, in writing, at
any time. If you revoke your permission, we will no longer use or
disclose medical information about you for the reasons covered by your
written authorization.
Name of Consumer: _____________________________________________
Consumer's Signature: ____________________________________________ Date:
_________________
Witness's Signature: _____________________________________________ Date:
_________________
Witness's Signature: _____________________________________________
Date: _________________
Reason Given by Consumer for Refusing to Sign this Notice
