Notice Of Privacy




FORMS: Notice of Privacy Practices and Acknowledgement of Receipt


HIPAA Privacy Policy 45 CFR 164.520(a) HITECH Act of 2009



This Notice describes the practices of HOME CARE SERVICES FOR INDEPENDENT LIVING (Provider) relating to your medical information and the practices of:

·      any health care professional authorized to enter information into your medical record;

·      all departments and units of the agency;

·      all employees, volunteers, staff of the agency and other agency personnel;

·      any other entities, sites and locations that have agreed to participate with the agency as part of an organized health care arrangement for purposes of complying with the Health Insurance Portability and Accountability Act of 1996 and regulations passed there under, commonly known as HIPAA. A complete list of these entities, sites and locations is provided at the end of this Notice, although this list may change from time to time. In addition, these entities, sites and locations may share medical information with each other for purposes of treatment, payment and certain health care operations related to the organized health care arrangement.


The agency understands that medical information about you and your health is personal. Provider is committed to protecting your medical information. Provider will create a record of the care and services you receive from Provider. This record is necessary to provide you with quality care and to comply with legal requirements. This Notice applies to all of the records of your care generated by the agency or on agency premises.

This Notice will tell you about the ways in which the agency may use and disclose your medical information. This Notice also describes your rights and certain

Notice of Privacy Practices obligations of the agency regarding the use and disclosure of your medical information.

The agency is required by HIPAA to:

·      Maintain the privacy of your medical information in compliance with legal requirements;

·      Give you this Notice of the agency legal duties and privacy practices with respect to your medical information; and

·      Follow the terms of this Notice that are currently in effect.

Generally, the agency may not use or disclose your medical information without your permission, except as otherwise permitted under HIPAA or other applicable law. Further, once your permission has been obtained, the agency must use or disclose your medical information in accordance with the specific terms of your permission. The following are the circumstances under which the agency is permitted by law to use or disclose your medical information.



Without your authorization, HIPAA allows the agency to use or disclose your medical information to provide you with services and the treatment you require or request, or to collect payment for those services, and to conduct other related health care operations otherwise permitted or required by law. Also, the agency is permitted to disclose your medical information within and among its workforce and other entities that have agreed to be bound by these policies to accomplish these same purposes. However, even with your authorization, the agency is still required to limit such uses or disclosures to the minimal amount of medical information that is reasonably required to provide those services or complete those activities.

The following categories describe different ways that the agency uses and discloses medical information. For each category of uses or disclosures, this Notice will explain what the agency means and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways in which the agency is permitted to use and disclose information without your authorization should fall within one of the categories.

·      For Treatment - the agency may use medical information about you to provide you with medical treatment or services. The agency may disclose medical information about you to doctors, nurses, technicians, volunteers, medical students, residents, other agency personnel or members of its workforce `who are involved in taking care of you on the agency premises. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that arrangements can be made for appropriate meals. Different departments of the agency also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. The agency also may disclose medical information about you to people outside of the agency who may be involved in your medical care after you leave the agency, such as family members, clergy or others whom Provider uses or who you or another responsible party have selected to provide services that are part of your care. 

·      For Payment - the agency may use and disclose medical information about you so that the treatment and services you receive from the agency can be billed to, and payment can be collected from, you, an insurance company or third-party payer. For example, the agency may need to give your health plan information about surgery you received so your health plan will pay the agency or reimburse for the surgery. The agency may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether our plan will cover the treatment.

·      For Health Care Operations - the agency may use and disclose medical information about you for the agency operations. These uses and disclosures are necessary to run the agency, to comply with accreditation and other standards and to make sure that all Provider patients receive quality care. For example, the agency may use your medical information to review its treatment and services and to evaluate the performance of the agency staff in caring for you. The agency may also combine medical information about many the agency patients to decide what additional services the agency should offer, what services are not needed, and whether certain new treatments are effective. The agency may also disclose information to doctors, nurses, technicians, medical students, residents, professional students, trainees or practitioners in health care, non-health care professionals and other agency personnel or members of its workforce for review, education, teaching and learning purposes. The agency may also combine the medical information it has with medical information from other providers to compare how the agency is doing and to see where the agency can make improvements in its care and services. The agency 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 your identity or the identity of any specific patient.


In addition, under HIPAA, the agency may use and disclose medical information, without your authorization, as follows:

·      To Send You Treatment Reminders and Information About Treatment Alternatives or Health-Related Benefits and Services - the agency may

 ·      contact you as a reminder that you have an appointment for treatment medical care with the agency or inform you about or recommend possible treatment options, alternatives or health-related benefits or services that maybe of interest to you. 

·      Fundraising Activities - the agency may contact you in an effort to raise money for the agency and its operations. The agency may disclose medical information to a foundation related to the agency so that the foundation may contact you in raising money for the agency. The agency would only release (i) contact information, such as your name, address and phone number; (ii) demographic information, such as your age, gender, insurance status and employer name; and (iii) the dates you received treatment or services from the agency. If you do not want the agency to contact you for fundraising efforts, you must notify the Privacy Officer in writing.

·      Provider Directory - the agency may include certain limited information about you in the agency directory while you are a patient on the agency premises. This information may include your name, location in the agency (e.g., floor, unit or wing), 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 (either in person or by telephone, electronic mail, etc.). This is so your family, friends and clergy can visit you and generally know how you are doing. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. If you would like to restrict or prohibit Provider's use or disclosure of your information for the agency directory, you must notify the Privacy Officer in writing, or, if the agency is a Hospital, you may notify the agency Admissions Department orally at the time of your admission to the agency.

·      Individuals Involved in Your Care or Payment for Your Care - the agency may release medical information about you to a family member, personal representative or friend who is involved in your medical care or who helps pay for your care. The agency may also tell these people about your condition and your location in the agency or attempt to locate or identify your family, representative or friends. In addition, the agency 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. Further, the agency may make disclosures to a parent, guardian or other person acting in place of a parent if such person has the authority to act on behalf of a minor. Additionally, the agency may make disclosures to a person appointed by you as your durable power of attorney for health care.

·      Public Health Activities - the agency may disclose information about you for public health activities, such as:

§ to prevent or control disease, injury or disability;

§ to report births and deaths;

§ to report child abuse or neglect;

 § to collect or report reactions to medications, food supplements or dietary supplements;

§ to collect or report product problems or defects;

§ to notify persons of recalls, replacements or repairs relating to products they may be using; and

§ to notify a person who may have been exposed to a disease or maybe at risk for contracting or spreading a disease or condition.

·      Disclosures About Victims of Abuse, Neglect or Domestic Violence – the agency may disclose medical information to notify the appropriate government authority if the agency believes a patient has been the victim of abuse, neglect or domestic violence. The agency will only make this disclosure if the patient agrees or when required or authorized by law.

·      Health Oversight Activities - the agency may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure or disciplinary actions. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

·      As Required by Law – the agency 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 - Consistent with Ohio law, the agency may use and disclose certain medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. In addition, the agency may use and disclose medical information if Provider believes that the use or disclosure is necessary for law enforcement to identify or apprehend an individual who has escaped from a correctional institution or from custody.

·      Organ and Tissue Donation - the agency may use or disclose information to an organ procurement or transplant organization or other similar entity.

·      Workers' Compensation - the agency may release information about you as authorized by (or as necessary to comply with) workers' compensation laws. For example, the agency may release information to a party responsible for payment of workers' compensation benefits and to an agency responsible for administering and/or adjudicating claims for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

·      Law Enforcement or Judicial or Governmental Proceedings - the agency may disclose medical information for law enforcement purposes or for judicial or governmental proceedings. For example, the agency may disclose medical information:

 § to report certain types of wounds or injuries;

§ in response to a court order or court-ordered subpoena (or court-ordered discovery request) or in response to a subpoena or discovery request if the patient privilege has been waived;

§ in response to a court-ordered warrant, subpoena or summons issued by a judicial officer, or a governmental request (including a governmental subpoena or summons) if certain standards are satisfied;

§ in response to a law enforcement official's request for the purpose of identifying or locating a suspect, fugitive, material witness or missing person, but only certain types of information may be disclosed;

§ to provide information about the victim of a crime, although the agency would try to obtain the individual's consent unless the individual is incapacitated or except under certain limited circumstances;

§ about an individual that has died to a law enforcement official for the purpose of alerting law enforcement of the death if the agency has a suspicion that such death may have resulted from criminal conduct;

§ about criminal conduct that occurred on the agency premises; and

§ in emergency circumstances to report a crime; the location of the crime or victims of the crime; or the identity, description or location of the person who committed the crime.

·      Coroners, Medical Examiners and Funeral Directors - the agency may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. The agency may also release medical information to funeral directors as necessary to carry out their duties.

·      For Specific Government Functions - the agency may release medical information of military personnel (and foreign military personnel) in certain situations, and the agency may release the medical information of inmates to correctional facilities in certain situations. The agency may also release medical information for national security reasons, such as the protection of the President of the United States or for national security activities.



Certain provisions of NYS law may be more stringent than HIPAA or may be, in the future, determined to be more stringent than HIPAA. If such provisions are more stringent than HIPAA, then, according to HIPAA, the agency must comply with the more stringent provisions of Ohio law.



Other uses and disclosures of medical information not covered by this Notice or the laws that apply to the agency will be made only with your written authorization. If you give the agency authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at anytime. If you revoke your authorization, the agency will no longer use or disclose medical information about you for the reasons covered by your written authorization, unless you authorized disclosure for a research study and your information is needed to protect the integrity of the study.

You understand that the agency is unable to take back any disclosures which the agency has already made with your authorization, and that the agency is required to retain its records of the care which the agency provides to you. All notices that you are revoking your authorization must be in writing and delivered by U.S. mail, in person, or by other reasonable means to the Privacy Officer.



You have the following rights regarding medical information, which the agency maintains about you:

·      Right to Inspect and Copy - You have the right to inspect and have a copy made of the medical information contained in your designated record set. A "designated record set" contains medical and billing records and any other records that the agency uses for making decisions about you. Usually, you have the right to access medical and billing records, subject to certain limitations. For example, you do not have the right to obtain information if its disclosure would have an adverse effect on you or if the information is compiled by the agency in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. Under HITECH, if a covered entity maintains an electronic health record for an individual, the individual may request access to the information in an electronic format or have the information transmitted electronically to a designated recipient.  
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the agency Privacy Officer. If you request a copy of the information, the agency may charge are atonable, cost-based fee to cover the costs associated with your request.
The agency may deny your request in very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the agency will review your request and the denial. The person conducting the review will not be the person who denied your request. The agency will comply with the outcome of the review.  

·      Right to Amend - If you feel that the medical information in the designated record set which Provider maintains about you is incorrect or incomplete, you may ask the agency to amend the information. You have the right to request an amendment for as long as the information is kept by or for the agency.
To request an amendment, you must make the request in writing and submit it to the Privacy Officer. In addition, you must provide a reason that supports your request.
The agency 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, the agency may deny your request if you ask the agency to amend information that:

§ was not created by the agency, 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 agency;

§ 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 Certain Disclosures - You have the right to request an accounting of certain disclosures, which the agency made of your medical information within the six years prior to your request. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures we may have made to you, with your authorization, for a facility directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Under HITECH, individuals may now receive an accounting of routine disclosures of PHI if the PHI is maintained in an electronic health records system, for the three year period prior to the date of the request.

To request this list or an accounting of the disclosures of your medical information, 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 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, the agency may charge you a  reasonable, cost-based fee for the cost of providing the list. Provider 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 the agency uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information the agency discloses 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 Provider not use or disclose information about a surgery you had. Under HITECH, a covered entity must comply with a patient's request to restrict information if the information is to be sent to a health plan for payment or health care operations purposes and the disclosure relates to products or services that were paid for solely out-of-pocket (unless the disclosure is      otherwise required by law).  

·      Provider is NOT required to agree to your request. If the agency does agree, the agency will comply with your request unless the information is needed to provide you with emergency treatment.
To request restrictions, you must make your request in writing to the Privacy Officer. In your request, you must tell the Privacy Officer: (i) what information you want to limit; (ii) whether you want to limit the agency use, disclosure or both; and (iii) to whom you want the limits to apply, for example, disclosure to your spouse or your former clergy.

·      Right to Request Change in Communications - You have the right to request that the agency communicate with you about your medical information in a certain way or at a certain location. For example, you can ask that the agency only contact you at work or by mail.
To request a change in the manner or method of how the agency communicates with you about your medical information, you must make your request in writing to the Privacy Officer. The agency will not ask you the reason for your request. The agency will use reasonable efforts to 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 receive a paper copy of this Notice. You may ask the agency to give you a copy of this Notice at any time.
 To obtain a paper copy of this Notice, please contact the Privacy Officer.



Provider reserves the right to change this Notice. The agency reserves the right to make the revised or changed Notice effective for all medical information which the


Notice of Privacy Practices

agency already has about you as well as any information the agency receives or creates in the future. The Notice will prominently display its effective date. The agency will post a copy of its current Notice at Provider's location and at in the lobby of the agency.



If you believe your privacy rights have been violated, you may file a complaint with the agency or with the Secretary of the Department of Health and Human Services. To file a complaint with the agency, contact the Privacy Officer. All complaints must be submitted in writing.

You will not be penalized by the agency on the grounds that a complaint was filed


If you have any questions about this Notice, please contact:

Phone: 1-718-627-1150 .

Please call the Front-Desk Ext.100 for office appointments.

Fax: 1-718-627-2165

Office : 9am - 5pm


Acknowledgement of Receipt of Notice of Privacy Practices


I acknowledge that I have been provided with a copy of Home care, Inc. Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything I did not understand.

Additionally, I will not disclose to anyone outside the hospital any incidental disclosure of information regarding any patient at the hospital during my stay.

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