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Form 990

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.

South Central Kansas Area Agency on Aging is required, by law, to maintain the privacy and confidentiality of your protected health information. This Notice of Privacy Practices describes how we may use and disclose you protected health information to carry out treatment, payment, or health care and your rights to access and control your protected information. "Protected health information" is information about you, and that relates to your past, present or future physical or mental health and related health care services.

1. Disclosure of Your Health Care Information

You will be asked by the Case Manager to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, South Central Kansas Area Agency on Aging will use or disclose your protected health information as explained below.

Examples of the types of uses and disclosures of your protected health care information the South Central Kansas Area Agency on Aging is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosure that may be made by Windsor Place once you have provided consent.

Treatment
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example)
"On occasion, it may be necessary to seek services regarding your needs. The Case Manger will record in your record this information and will share this information with your provider or other sources as needed, i.e. durable medical equipment provider."
Payment
We may disclose your health information to your insurance provider, as needed, to obtain payment for your health care services. (example)
"Your protected health information may be disclosed for billing purposes of case management services."
Health Care Operations
We may disclose, as needed, your protected health information to conduct internal business. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, marketing, and conducting or arranging for other business activities.

Marketing
We may contact you for marketing purposes or fundraising purposes, as described below. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer or your Case Manager to request that these materials not be sent to you. (example)
"As a courtesy to our clients, it is our policy to call your home to your scheduled appointment If you are not at home, we leave a message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than to request you return the call. "

"Occasionally we will provide advertisement for one of our government funded programs. During these times, we have asked for volunteers to participate in this activity, i.e. picture on a brochure.
Emergencies
We may disclose your protected health information in an emergency treatment situation death.

Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to coordinate uses and disclosures to family or other individuals involved in your health care.

Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, and reporting disease or infection exposure. We may also disclose your protected health information if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Abuse or Neglect
We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Legal Proceedings
We may disclose your protected health information in the course of any administrative or judicial proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain condition in response to a subpoena, discovery request or other lawful process.

Law Enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) crime. (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of South Central Kansas Area Agency on Aging, and (6) medical emergency (not at South Central Kansas Area Agency on Aging) and it is likely that a crime has occurred.

Health Oversight
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Food and Drug Administration
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Deceased Persons
We may disclose your health information to coroners or medical examiners.

Organ Donation
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

Research
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board of Kansas Department of Aging.

Workers' Compensation
Your protected health information may be disclosed by South Central Kansas Area Agency on Aging as authorized to comply with workers' compensation laws and other similar legally established programs.

Public Safety
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Military Activity and National Security
When the appropriate conditions apply, we use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities: (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized.

2. Change of Ownership. In the event that South Central Kansas Area Agency on Aging is merged with another organization, your health information/record will become the property of the new agency.

3. Your Health Information Rights
  • You have the right to request restrictions on certain uses and disclosures of your health information. This means you may ask us not to use or disclose nay part of your protected health information for the purposes of treatment. Payment or healthcare operations. You may also request that nay part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

    Please be advised, however, that South Central Kansas Area Agency on Aging is not required to agree to the restriction that you requested. If South Central Kansas Area Agency on Aging believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If South Central Kansas Area Agency on Aging does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request from South Central Kansas Area Agency on Aging with your Case Manager or with the Privacy Officer.
  • You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to your Case Manager or to the Privacy Officer.
  • You have the right to inspect and copy your health information. This means you may inspect and obtain a copy of protected health information about you that is contained in your chart for as long as we maintain the protected health information.

    Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed.
  • You have a right to request that South Central Kansas Area Agency on Aging amend your protected health information. Please be advised, however, that South Central Kansas Area Agency on Aging is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
  • You have a right to receive an accounting of certain disclosures of your protected health information made by South Central Kansas Area Agency on Aging. This right applies to disclosures for purposes we may have made to you, for a facility directory, to family members or friends involved in your care for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
  • You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
South Central Kansas Area Agency on Aging reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all protected health information that we maintain at that time. Until such amendment is made, South Central Kansas Area Agency on Aging is required by law to comply with this Notice. Upon request, we will provide you with any revised Notice of Privacy Practices by accessing our website at www.sckaaa.org or by calling our office and requesting that a revised copy be sent to you in the mail.

South Central Kansas Area Agency on Aging is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Virginia Von Cannon by calling this office at 1-800-362-0264. If Virginia Von Cannon is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints
Complaints about your Privacy rights, or how South Central Kansas Area Agency on Aging has handled your health information should be directed to Virginia Von Cannon by calling this office at 1-800-362-0264. If Virginia Von Cannon is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. We will not retaliate against you for filing a complaint.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.
Room 509F HHH Building
Washington, DC 20201
This notice is effective as of 04 / 14 / 03

I have read the Privacy Notice and understand my rights contained in the notice.

By way of my signature, I provide South Central Kansas Area Agency on Aging with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice
_______________________________________
Patient's Name (print)

__________________________ __________
Patient's Signature

Date
__________________________ __________
Authorized Facility Signature Date
~ Serving 10 counties ~
Chautauqua · Cowley · Elk · Greenwood · Harper · Kingman · McPherson · Reno · Rice · Sumner
South Central Kansas Area Agency on Aging (SCKAAA)
304 S. Summit _ P.O. Box 1122, Arkansas City, KS 67005
Bus: 620-442-0268 · Fax: 1-620-442-0296
E-mail: info@sckaaa.org


Older Kansan's Hotline: 1-800-362-0264
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