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For Your Protection: This notice describes how medical information about
you may be used and disclosed and how you can get access to this
information.
Private
Information:
You may be applying for, or participating in, Government programs that
provide money or services (ex. Medicare, Medicaid uses). So that we can
file your insurance, you need to give us personal information about you.
The laws say that:
- We must keep your
information from others who do not need to know it.
- You need to tell us
what information we can share and when we can share it.
Who sees my information?
Your information is only provided to the programs you list. We will not
share information with any other programs unless you ask us to do so.
What about my Medical Information?
Healthcare providers who take care
of you may use your private medical information. This may cover health
care you had before now, or may have later on.
What all is Shared?
We only share information about you that is
needed at that time by that provider or agency to do their job.
How is Insurance Billed?
Your healthcare provider sends a bill to an
insurance company or to a government program to get paid, if applicable.
May I See my Medical Information?
You are allowed to see your
medical information. Most of the time you can receive a copy if you ask.
You may ask for a list of any places where medical information may have
been sent if it was not sent as part of your provider’s care or used to
be sure that you received quality care and that all laws about medical
care are met.
What if my Medical Information needs to
go Somewhere Else? You will be
asked to sign an authorization form allowing your medical information to
be shared if:
- Your healthcare
provider needs to send it to other places;
- You want us to send
it to another healthcare provider; or,
- You want it sent to
another person for you.
The form tells us what, where and to whom
the information must be sent.
Your authorization is good for 6 months or
until the date you put on the form. You can cancel or limit the amount
of information sent at any time by letting us know in writing.
| Note:
If you are less than 18
years old, your parents or guardians will receive your private
medical information, unless you are able to consent for your own
healthcare treatment. If you are, then it will not be shared
with your parents or guardians unless you sign an authorization
form. |
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Could Medical Information be Released
Without my Authorization? There
are laws that tell us when we have to release private medical
information, even if you do not sign an authorization form. We always
report:
- Contagious
diseases;
- Reactions and
problems with treatments;
- To the police when
they are investigating a crime, when child or elderly abuse may be
happening, or when the court orders us to;
- To the government
to review how the Medicaid program is working;
- To a provider or
other insurance who needs to know if you have Medicaid;
- Work related
injuries to workers compensation;
- To the Federal
Government when they are investigating something important to
protect our country, the President and other government workers.
May I Have a Copy of This Notice?
This notice is yours. If anything
changes, you will get a new one. If you have any questions about this
notice, please ask the person who gave it to you. If there are questions
that cannot be answered, you can call the State Department of Human
Rights Commission. You can complain to the Secretary of Health and Human
Services of the Federal Government by writing to 200 Independence Ave.
SW, Washington, DC 20201. You need to do so within 180 days of when the
problem that concerned you happened. You could also complain to the
Office for Civil Rights by calling 866-627-7748.
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