There are some things that you can do to help protect the security of your information as well. For instance, never give out your password. Personal information will not be released to third parties. There are no circumstances under which we will provide or sell personal information to third parties. If you need further assistance, please:
1) Send an e-mail with your questions or comments to firstname.lastname@example.org
2) Write us at: Tulsa Boys’ Home, PO Box 1101, Tulsa, OK, 74101
3) Fax us at: 918-241-5031* or
4) Call us at 918-245-0231*
*You must be at least 18 years old or have permission from your parent to call or fax the above numbers.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
This notice describes how medical information about you may be used and disclosed and how you can get access to this Information. Please review carefully.
We understand that medical and mental health information about you is personal. We are committed to protecting this information. A confidential case record is created of the care and services received at TBH. This record is needed to provide documentation of the necessary care and to comply with legal requirements.
This notice describes how we may use and/or disclose your Protected Health Information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control PHI. PHI is information about you, including demographic information that my identify you and that relates to past, present or future physical and mental health.
Who Will Follow This Notice?
This notice describes the privacy practices of TBH entities including those of:
- Any health care professional authorized to enter information into the case record.
- Any member of an authorized volunteer group we allow to help the client while he is provided care.
All the above individuals and/or entities and TBH locations will follow the terms of this notice. In addition, they may share client information with each other for purposes of treatment, payment, or health care operations as described in this notice. TBH is required by law to:
- Make sure that information that identifies any client is kept confidential.
- Give you this notice of our legal duties and privacy practices with respect to client information.
- Follow the terms of the notice that is currently in effect.
TBH has the right to change this notice and make revisions and to make any such changes effective for all PHI that TBH maintains at the time of such change. Each time you are admitted, you will obtain a copy of our most current notice.
SECTION 1. Uses And/Or Disclosures Of Protected Health Information.
Your PHI may be used and/or disclosed by TBH staff or authorized volunteers that are involved in your care and treatment for the purpose of providing health care services to you and purposes specified below. Other uses and/or disclosures will be made only with your authorization and at anytime you have the right to revoke such authorization. PHI may be disclosed in oral, written or electronic format. PHI will be retained according to state statutes and disposed of following agency policy. PHI includes information about individuals living or deceased.
Minimum Necessary: PHI disclosed to individuals as part of Treatment, Payment or Operations shall be the minimum amount of information necessary to conduct client services. The following are examples of the types of uses and disclosures of your PHI that TBH is permitted to make:
Treatment: We will use and/or disclose your PHI to provide, coordinate or manage your health care, including mental health, and any related services. For example, we may disclose your PHI for the coordination or management of your health care with a third part that has already obtained your permission to have access to your protected health information. In addition, we may disclose your PHI to another entity or health care provider who becomes involved in your care, by providing assistance with your health care or treatment.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you. For example, it includes making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Healthcare Operations: We may use and/or disclose, as needed, your PHI in order to support the business activities of TBH. For example, these activities include, but are not limited to, quality assessment activities, employee review activities, training of students (interns), licensing, accreditation, and conducting or arranging for other business activities.
Business Associates: We may disclose PHI to other persons or organizations, known as Business Associates, who provide services on our behalf under contract. We will have Business Associate Agreements with those entities that assist us in providing client services. To protect your health information, we require our Business Associates to appropriately safeguard the information we disclose to them.
Fundraising: We may use your PHI to contract you for certain fundraising purposes. If you do not wish for us to do so, please contact the HIPAA Compliance Officer.
Health Oversight: We may disclose your PHI to an oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government regulatory programs and civil rights laws.
Treatment Alternatives: We may use and/or disclose PHI to tell you about or recommend possible treatment options or alternatives of interest.
Abuse and Neglect: We may disclose your PHI to a public health authority that is authorized by law to receive reports of alleged or actual child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been an alleged or actual victim of abuse, neglect, or domestic violence.
To Avert A Serious Threat To Health or Safety: We may use and/or disclose PHI about you when necessary to prevent serious threat to your health and/or safety of the public or another person (e.g. communicable disease).
Food and Drug Administration: We may disclose PHI to a person or company required by the Food and Drug Administrations to report adverse events, product defects, or problems, biological product deviations, track products, to enable product recalls, to make repairs or replacements or to conduct post marketing surveillance, as required.
As Required By Law: We may use and/or disclose PHI to the extent that the use and/or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements by the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purposes of controlling disease, injury or disability. We may also disclose PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Appointment Reminders: We may use and/or disclose information to contact you as a reminder for an appointment for treatment.
Research: Under certain circumstances, your PHI may be used or disclosed for research purposes, upon your written authorization if a waiver of individual authorization is approved by an Institutional Review Board or privacy board and other requirements are met.
Law Enforcement: We may disclose PHI, so long as applicable legal requirements are met for law enforcement purposes. These law enforcement purposes include legal processes as otherwise required by law, limited information requests for identifications and location purposes pertaining to victims of crimes, suspicion that death has occurred as a result of criminal conduct, or in the event that the crime occurs while you are under the auspices of our care, or in a medical emergency when it is likely that a crime has occurred.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Lawsuits and Disputes: We may disclose PHI about you in response to a court or administrative order. We may also disclose information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, and shall make efforts to tell you about the request or obtain an order protecting the information requested.
Military Activity and National Security: When the appropriate conditions apply, we may use and/or disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities.
Coroner, Funeral Directors, and Organ Donations: We may disclose PHI to a coroner or medical examiner for identification purposes, determining the cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may also be used and/or disclosed for organ donation purposes.
Worker’s Compensation: We may disclose PHI about you for workers’ compensation laws and similar programs.
Person Involved In Your Care: TBH may use and disclose your PHI to notify or assist in notification of a family member or close personal friend involved in your care of your location, condition or death, when directly relevant to such person’s involvement with your care or payment related to your care, if you agree to such disclosure. If you are not present or unable to agree because of either incapacity or an emergency situation, TBH may use or disclose PHI that is directly relevant to your care, to a family member or close personal friend if TBH determines it is in your best interest to do so.
SECTION 2. Your Rights Regarding PHI. To exercise any of the rights described in this section please contact the HIPAA Compliance Officer. The contact information for the HIPAA Compliance Officer is listed at the end of this notice.
Authorization To Use Or Disclose Your PHI: Other uses and/or disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your authorization. If you provide us authorization to use or disclose PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your prior authorization and that we are required to retain records of the care provided. Your authorization is required to conform to any state law requirements that are more stringent than federal law.
You Have The Right To Inspect And Copy Your PHI: You have the right to inspect and copy your PHI that may be used to make decisions about your care. To inspect or copy your PHI, you must submit a written request. We may deny your request to inspect or copy in some circumstances. If you are denied access to PHI, you may request that the denial be reviewed by a different party.
Right To Amend Your Record: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information by filling out the HIPAA “Request To Amend” form. The request must be submitted in writing to the Licensed Practical Nurse or his/her designee. In addition, you must provide a reason that supports your request for amendment. If your request to amend is denied, you have the right to file a statement of disagreement with TBH. In addition, we may deny your request in certain situations, such as if you ask us to amend any of the following information that was not created by TBH, not part of the client case record kept by TBH, not part of the information which you would be permitted to inspect and copy under the law 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 your PHI for certain limited purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003 and you must submit your request in writing. TBH will provide the first accounting you request free of charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
Right To Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for Payment, Treatment or Health Care Operations. You also have the right to request a limit on the PHI we disclose to someone who is involved in your care. Your request must state the specific restrictions requested and to whom you want the restriction to apply. TBH is not required to agree to your request.
Right To Request Confidential Communication: You have the right to request that we communicated with you about your PHI in a certain way or at a certain location. You must request in writing, how or where you wish to be contacted.
Right To Receive A Paper Copy: You have the right to receive a paper copy of this notice. Even if you agreed to this notice electronically, you have the right to a paper copy.
Right To File A Complaint: If you believe that your rights have been violated, you may file a complaint with TBH or with the US Secretary of the Department of Health and Human Services. All complaints to TBH must be submitted in writing to the HIPAA Compliance Officer at the address below. TBH will not retaliate against you for filing a complaint.
Contact Information For HIPAA Compliance Officer:
TBH has designated its Quality Assurance Coordinator as the HIPAA Compliance Officer and contact person for all issues, questions or concerns regarding our privacy practices. You may contact the HIPAA Compliance Officer at (918) 245-0231 or P.O. Box 1101, Tulsa, OK 74101.
The effective date of this notice is ________June 15, 2004___.