LIFE STYLES, INC. NOTICE OF PRIVACY PRACTICES
Effective: April 14, 2003
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.
This notice will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. In the header above, that information is referred to as ìmedical information.î In this notice, we simply call all of that protected health information, ìhealth information.î
This notice also will tell you about your rights and our duties with respect to health information about you. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.
How We May Use and Disclose Health Information About You.
We use and disclose health information about you for a number of different purposes. Each of those purposes is described below.
• For Treatment.
We may use health information about you to provide, coordinate or manage the services, supports, and health care you receive from us and other providers. We may disclose health information about you to doctors, nurses, qualified mental retardation professionals (QMRPs), psychologists, social workers, direct support staff and other agency staff, volunteers and other persons who are involved in supporting you or providing care. We may consult with other health care providers concerning you and, as part of the consultation, share your health information with them. For example, staff may discuss your information to develop and carry out your individual service plan. Staff may share information to coordinate needed services, such as medical tests, transportation to a doctorís visit, physical therapy, etc. Staff may need to disclose health information to entities outside of our organization (for example, another provider or a state/local agency) to obtain new services for you.
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• For Payment.
We may use and disclose health information about you so we can be paid for the services we provide to you. This can include billing a third party payor, such as Medicaid or other state agency (for example, Arkansas Developmental Disabilities Services), or your insurance company. For example, we may need to provide the state Medicaid program information about the services we provide to you so we will be reimbursed for those services. We also may need to provide the state Medicaid program with information to ensure you are eligible for the medical assistance program.
• For Health Care Operations.
We may use and disclose health information about you for our own operations. These are necessary for us to operate Life Styles and to maintain quality for the consumers we serve. For example, we may use health information about you to review the services we provide and the performance of our employees supporting you. We may disclose health information about you to train our staff and volunteers. We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program.
• Appointment Reminders. We may use and disclose health information about you to contact you to remind you of
an appointment for treatment or services.
• Treatment and Service Alternatives. We may use and disclose health information about you to contact you about treatment
and service alternatives that may be of interest to you.
• Health Related Benefits and Services. We may use and disclose health information about you to contact you about health-
related benefits and services that may be of interest to you.
• Marketing Communications. We may use and disclose health information about you to communicate with you about a
product or service to encourage you to purchase the product or service. This may be: © John C. Gilliland II (Page 2)
• To describe a health-related service that is provided by us;
• For your treatment/ support
• For case management or care coordination for you;
• To direct or recommend alternative treatments, therapies, health care providers, or settings of care.
We may communicate to you about products and services in a face-to-face communication by us to you.
All other use and disclosure of health information about you by us to make a communication about a product or service to encourage the purchase or use of a product or service will be done only with your written authorization.
We may use and disclose health information about you to raise funds for Life Styles. We may disclose health information to a business associate of Life Styles or Life Styles Foundation, Inc. so that business associate or the foundation may contact you to raise money for the benefit of Life Styles. We will only release demographic information, such as your name and address, and the dates you received services from Life Styles. If you do not want Life Styles or its foundation to contact you for fundraising, you must notify Life Styles Executive Director in writing.
• Disclosures to Family and Others.
We may disclose to a parent/guardian, personal representative, family member, other relative, a close personal friend, or any other person identified by you, health information about you that is directly relevant to that personís involvement with the services and supports you receive or payment for those services and supports. We also may use or disclose health information about you to notify, or assist in notifying, those persons of your location, general condition, or death. If there is a family member, other relative, or close personal friend that you do not want us to disclose health information about you to, please notify our Executive Director or tell our staff member who is providing care to you.
• Disaster Relief. We may use or disclose health information about you to a public or private entity
authorized by law or by its charter to assist in disaster relief efforts. This will be done to © John C. Gilliland II (Page 3)
coordinate with those entities in notifying a parent/guardian, personal representative, family member, other relative, close personal friend, or other person identified by you of your location, general condition or death.
• Required by Law. We may use or disclose health information about you when we are required to do so by
• Public Health Activities.
We may disclose health information about you for public health activities and purposes. This includes reporting health information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.
• Victims of Abuse, Neglect or Domestic Violence.
We may disclose health information about you to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you or your personal representative; or, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or, if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
• Health Oversight Activities.
We may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.
• Judicial and Administrative Proceedings.
We may disclose health information about you in the course of any judicial or © John C. Gilliland II (Page 4)
administrative proceeding in response to an order of the court or administrative tribunal. We also may disclose health information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.
• Disclosures for Law Enforcement Purposes. We may disclose health information about you to a law enforcement official for law
enforcement purposes: a. As required by law. a. In response to a court, grand jury or administrative order, warrant or subpoena. b. To identify or locate a suspect, fugitive, material witness or missing person.
c. About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that personís agreement, in limited circumstances, the information may still be disclosed.
d. To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
e. About crimes that occur at our facility. f. To report a crime in emergency circumstances.
• Coroners and Medical Examiners. We may disclose health information about you to a coroner or medical examiner for
purposes such as identifying a deceased person and determining cause of death.
• Funeral Directors. We may disclose health information about you to funeral directors as necessary for them
to carry out their duties.
• Organ, Eye or Tissue Donation. To facilitate organ, eye or tissue donation and transplantation, we may disclose health
information about you to organ procurement organizations or other entities engaged in © John C. Gilliland II (Page 5)
the procurement, banking or transplantation of organs, eyes or tissue.
To Avert Serious Threat to Health or Safety.
We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.
We may disclose health information about you for the following reasons: National Security and Intelligence; Protective Services for the President.
Inmates; Persons in Custody.
We may disclose health information about you to a correctional institution or law enforcement official having custody of you. The disclosure will be made if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or, (c) the safety, security and good order of the correctional institution.
We may disclose health information about you to the extent necessary to comply with workersí compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying the Privacy Officer in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Health Information About You.
You have the following rights with respect to health information that we maintain about
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• Right to Request Restrictions.
You have the right to request that we restrict the uses or disclosures of health information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) for to public or private entities for disaster relief efforts. For example, you could ask that we not disclose health information about you to your brother or sister.
To request a restriction, you may do so at any time. If you request a restriction, you should do so to the Privacy Officer and tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your spouse).
We are not required to agree to any requested restriction. However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.
• Right to Receive Confidential Communications.
You have the right to request that we communicate health information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication.
If you want to request confidential communication, you must do so in writing to our Privacy Officer. Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, if necessary, require information from you concerning how payment will be handled. We also may require an alternate address or other method to contact you.
• Right to Inspect and Copy. With a few very limited exceptions, such as psychotherapy notes, you have the right to
inspect and obtain a copy of health information about you.
To inspect or copy health information about you, you must submit your request in writing to the Privacy Officer. Your request should state specifically what health information you want to inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.
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We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
We may deny your request to inspect and copy health information if the health information involved is:
a. Psychotherapy notes;
b. Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding;
If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designed by us who was not directly involved in the denial. We will comply with the outcome of that review.
• Right to Amend. You have the right to ask us to amend health information about you. You have this right
for so long as the health information is maintained by us.
To request an amendment, you must submit your request in writing to the Privacy Officer. Your request must state the amendment desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
If we grant the request (in whole or in part) we will seek your agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the health information by appending or otherwise providing a link to the amendment.
We may deny your request to amend health information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend health information if we determine that the information:
a. Was not created by us, unless the person or entity that created the information is no longer available to act on the requested amendment;
b. Is not part of the health information maintained by us; © John C. Gilliland II (Page 8)
c. Would not be available for you to inspect or copy; or, d. Is accurate and complete.
If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreeing with our denial. Your statement may not exceed two pages. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the health information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the health information involved.
You also will have the right to complain about our denial of your request.
• Right to an Accounting of Disclosures.
You have the right to receive an accounting of disclosures of health information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.
Certain types of disclosures are not included in such an accounting: a. Disclosures to carry out treatment, payment and health care operations; b. Disclosures of your health information made to you; c. Disclosures that are incident to another use or disclosure; d. Disclosures that you have authorized; e. Disclosures for our facility directory or to persons involved in your care; f. Disclosures for disaster relief purposes; g. Disclosures for national security or intelligence purposes; h. Disclosures to correctional institutions or law enforcement officials;
i. Disclosures that are part of a limited data set for purposes of research, public health, or health care operations (a limited data set is where things that would
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directly identify you have been removed. j. Disclosures made prior to April 14, 2003.
Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and my not include dates before April 14, 2003.
Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.
• Right to Copy of this Notice.
You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even though you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time.
To obtain a paper copy of this notice, contact Life Styles Executive Director; P.O. Box 1114; Fayetteville, AR 72702
We are required by law to maintain the privacy of health information about you and to provide individuals with notice of our legal duties and privacy practices with respect to health information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the
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• Our Right to Change Notice of Privacy Practices.
We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new noticeís provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.
• Availability of Notice of Privacy Practices. A copy of our current Notice of Privacy Practices will be posted on the bulletin board in
the Support Center.
At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting Life Styles Executive Director; P.O. Box 1114 Fayetteville, AR 72702
• Effective Date of Notice. The effective date of the notice will be stated on the first page of the notice.
• Complaints. You may complain to us and to the United States Secretary of Health and Human
Services if you believe your privacy rights have been violated by us.
To file a complaint with us, contact Life Styles Executive Director; P.O. Box 1114; Fayetteville, AR 72702. All complaints should be submitted in writing.
To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.
You will not be retaliated against for filing a complaint.
• Questions and Information.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact Life Styles Executive Director; P.O. Box 1114; Fayetteville, AR 72702.
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