016.14.13 Ark. Code R. 005
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.
The Department of Human Services (DHS) provides many types of services, such as health and social services. DHS staff must collect information about you to provide these services. DHS knows that information collected about you and your health is private. DHS and all associates at all locations are required by law to maintain the privacy of patients' Protected Health Information (PHI) and to provide individuals with the Notice of the legal duties and privacy practices with respect to PHI.
DHS is required to give you a notice of our privacy practices for the information we collect and keep about you. We are required to abide by the terms of this Notice. We reserve the right to change the terms of this Notice and these new term will affect all PHI that we maintain at that time.
Revised notices may be picked up at any office or online at: http://humanservices.arkansas.gov.
In certain circumstances, DHS may use and disclose PHI without written consent.
For Treatment: We will use your health information to provide you with medical treatment or services. We will disclose PHI to doctors, nurses, technicians, students in health care training programs, or other personnel who are involved in taking care of you. Example-a doctor treating you for a broken leg may need to know if you have diabetes because that might slow the healing process. In addition, he/she may need to tell the dietitian to arrange for appropriate meals. Different departments of DHS may share health information about you in order to coordinate the services you need, such as prescriptions, lab work and x-rays. We may disclose health information to people outside DHS who provide your medical care like nursing homes or other doctors. We may tell your health insurer about treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment. We may contact you to provide reminders of appointments.
For Payment: DHS will use and disclose PHI to other health care providers to assist in payment of your bills. We will use it to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive.
Business Associates: We may use or disclose your PHI to an outside company that assists us in operating our health system and performs various services for us. This includes, but is not limited to, auditing, accreditation, legal services, and consulting services. These outside companies are called "business associates" and contract with us to keep PHI received confidential in the same way we do. These companies may create or receive PHI for us.
For Health Care Operations: DHS may use or disclose your PHI for the purpose of our business operations. These uses and disclosures are necessary to insure our patients receive quality care. For example, we may use PHI to review the quality of our treatment and services, and to evaluate the performance of staff, contracted employees and students in caring for you.
For Public Health Activities: DHS may use or disclose your PHI for public health activities that are permitted or required by law. Example-we may disclose PHI in certain circumstances to control or prevent a communicable disease; injury; disability; to report births and deaths; and for public health oversight activities or interventions. We may disclose PHI to the Food and Drug Administration (FDA) to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law or to state or federal government agencies. We may disclose PHI, if directed by a public health authority, to a foreign government agency that is collaborating with the public health authority.
For Health Oversight Activities: DHS may disclose PHI to a health oversight agency for activities authorized by law. For example, these oversight activities may include audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Agencies seeking this information include government agencies that oversee the health care system, benefit programs, other regulatory programs, and government agencies that ensure compliance with civil rights laws.
As Required by Law and For Law Enforcement: DHS will use and disclose PHI when required or permitted by federal, state, and local laws, or by court order. Under certain conditions, we may disclose PHI to law enforcement officials for law enforcement purposes. Example-these may include (1) responding to a court order or similar process; (2) as necessary to locate or identify a suspect, fugitive, material witness, or missing person; (3) reporting suspicious wounds, burns or other physical injuries; or (4) as relating to the victim of a crime
Lawsuits and Other Legal Proceedings: DHS may disclose PHI in the course of any judicial or administrative proceeding or in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). If certain conditions are met, we may disclose your PHI in response to a subpoena, a discovery request, or other lawful process.
Abuse or Neglect: We may disclose your PHI to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence. Additionally, as required by law, if we believe you have been a victim of abuse, neglect, or domestic violence, we may disclose your PHI to a governmental entity authorized to receive it.
For Government Programs: DHS may use and disclose PHI for public benefits under other government programs. For example, DHS may disclose PHI for the determination of Supplemental Security Income (SSI) benefits.
To Avoid Harm: DHS may disclose PHI to law enforcement in order to avoid a serious threat to the health and safety of a person or the public.
For Research: DHS may use and share your health information for certain kinds of research. Example: a research project may involve comparing the health and recovery of patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. In some instances, the law allows us to do some research using your PHI without your approval.
Family Members and Friends: If you agree, do not object, or we reasonably infer that there is no objection, DHS may disclose PHI to a family member, relative, or other person(s) whom you have identified to be involved in your health care or the payment of your health care. If you are not present, or are incapacitated, or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited PHI is in your best interest. We may disclose PHI to a family member, relative, or other person(s) who was involved in the health care or the payment for health care of a deceased individual if not inconsistent with prior expressed preferences of the individuals known to DHS. You also have the right to request a restriction on our disclosure of your PHI to someone who is involved in your care.
Coroners, Medical Examiners and Funeral Directors: DHS may release your PHI to a coroner or medical examiner. Example-this may be necessary to identify a deceased person or to determine cause of death. We may also release your PHI to a funeral director, as necessary, to carry out his/her duties.
Organ Donations: We will disclose PHI to organizations that obtain, bank or transplant organs or tissues.
National Security and Protection of the President: DHS may release your PHI to an authorized federal official or other authorized persons for purposes of national security, for providing protection to the President, or to conduct special investigations, as authorized by law.
Correctional Institution: If you are an inmate of a correctional institution or under the custody of a law enforcement officer, DHS may release your PHI to them. The PHI released must be necessary for the institution to provide you with health care, protect your or other's health and safety, or for the safety and security of the correctional institution.
Military: If you are a veteran or a current member of the armed forces, DHS may release your PHI as required by military command or veteran administration authorities.
Workers' Compensation: DHS will disclose your health information that is reasonably related to a worker's compensation illness or injury following written request by your employer, worker's compensation insurer, or their representative.
Employer Sponsored Health and Wellness Services: We maintain PHI about employer sponsored health and wellness services we provide our patients, including services provided at their employment site. We will use the PHI to provide you medical treatment or services and will disclose the information about you to others who provide you medical care.
Shared Medical Record/Health Information Exchanges: We maintain PHI about our patients in shared electronic medical records that allow the DHS associates to share PHI. We may also participate in various electronic health information exchanges that facilitate access to PHI by other health care providers who provide you care. Example-if you are admitted on an emergency basis to another hospital that participates in the health information exchange, the exchange will allow us to make your PHI available electronically to those who need it to treat you.
Other Uses and Disclosures of PHI
Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes and disclosures that constitute the sale of PHI require your written authorization.
Other uses and disclosures of your PHI that are not described above will be made only with your written authorization. If you provide DHS with an authorization, you may revoke it in writing, and this revocation will be effective for future uses and disclosures of PHI. The revocation will not be effective for information that we have used or disclosed in reliance on the authorization.
Your PHI Privacy Rights
The Right to Access to Your Own Health Information: You have the right to inspect and copy most of your protected health information for as long as we maintain it as required by law. All requests for access must be made in writing. We may charge you a nominal fee for each page copied and postage if applicable. You also have the right to ask for a summary of this information. If you request a summary, we may charge you a nominal fee.
Right to Inspect and Copy: You have the right to inspect and receive a copy of PHI about you that may be used to make decisions about your health. A request to inspect your records may be made to your nurse or doctor while you are an inpatient or to the DHS Privacy Officer while an outpatient. For copies of your PHI, requests must go to the DHS Privacy Officer. For PHI in a designated record set that is maintained in an electronic format, you can request an electronic copy of such information.There may be a charge for these copies
Right to Amend: If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information, for as long as DHS maintains the information. Requests for amending your PHI should be made to the DHS Privacy Officer. The DHS personnel who maintain the information will respond to your request within 60 days after you submit the written amendment request form. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.
Right to Request Confidential Communications: If you believe that a disclosure of all or part of your PHI may endanger you, you may request in writing that we communicate with you in an alternative manner or at an alternative location. For example, you may ask that all communications be sent to your work address. Your request must specify the alternative means or location for communication with you. It also must state that the disclosure of all or part of the PHI in a manner inconsistent with your instructions would put you in danger. We will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your protected health information could endanger you.
Right to Get a List of Disclosures: You have the right to ask DHS for a list of disclosures made after April 14, 2003. You must make the request in writing. With some exceptions, you have the right to receive an accounting of certain disclosures of your PHI. A nominal fee will be charged for the record search.
Right to Request Restrictions: You have the right to request certain restrictions of our use or disclosure of your PHI. We are not required to agree to your request in most cases. But if DHS agrees to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment. DHS will agree to restrict disclosure of PHI about an individual to a health plan if the purpose of the disclosure is to carry out payment or health care operations and the PHI pertains solely to a service for which the individual, or a person other than the health plan, has paid DHS for in full. For example, if a patient pays for a service completely out of pocket and asks DHS not to tell his/her insurance company about it, we will abide by this request. A request for restriction should be made in writing. To request a restriction you must contact the DHS Privacy Officer. We reserve the right to terminate any previously agreed-to restrictions (other than a restriction we are required to agree to by law). We will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to PHI created after we inform you of the termination.
Right to Revoke Permission: If you are asked to sign an authorization to use or disclose PHI, you can cancel that authorization at any time. You must make the request in writing. This will not affect PHI that has already been shared.
Right to File a Complaint: You have the right to file a complaint if you do not agree with how DHS has used or disclosed PHI about you.
Right to Get a Paper Copy of this Notice: You have the right to ask for a paper copy of this notice at any time
Right to be notified of a Breach: You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of unsecured protected health information involving your medical information.
See the contact information below:
to View, Inspect, Copy, or Amend your PHI,
to Request Confidential Communications,
to Request an accounting (list) of disclosures,
to Request Restrictions,
to Revise Authorizations, or
to File a Complaint.
This privacy notice is also available @
http://humanservices.arkansas.gov/Pages/DHS%20Notice%20of%20Privacy%20Practi
You may contact your local DHS office or the DHS Privacy Officer at the address listed below.
Arkansas Department of Human Services
DHS Privacy Officer
Department of Human Services
P.O. Box 1437, Slot S260
Little Rock, Arkansas 72203-1437
Telephone: 1-855-283 -0835
TDD: (501) 682-8933
Email: DHSPrivacyOfficer@arkansas.gov.
Office for Civil Rights
U.S. Department of Health & Human Services
1301 Young Street-Suite 1169
Dallas, TX 75202
(214) 767-4056; (214) 767-8940(TDD)
(214) 767-0432 Fax
ACKNOWLEDGEMENT OF RECEIPT of NOTICE OF PRIVACY PRACTICES
I, ___________________________ (print client's name or legal representative) have been given a copy of DHS' Notice of Privacy Practices and have had a chance to ask questions about how my PHI will be used.
Client's SignatureDate
Legal or PersonalRelationship
Representative of Client (if applicable)
File the original signed copy in the case record; give the recipient of this notice a copy of this document.
016.14.13 Ark. Code R. 005