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ADMINISTRATIVE/GENERAL ADMIN: 12.1.1

PAGE: 3
HIPAA COMPLIANCE – USES AND DISCLOSURES OF: 4

REVISED: 01/24
EFFECTIVE: 01/2024 REVIEWED: 01/24

We are permitted to use or disclose information about you without consent or authorization provided you are
informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the
following circumstances:
• Use of a directory (includes names, location, condition described in general terms) of individuals served by
our agency;
• To a family member, relative, friend, or other identified person, the information relevant to such person’s
involvement in your care or payment for care; to notify a family member, relative, friend, or other identified
person of the individual’s location, general condition, or death.

Other uses and disclosures will be made only with your written authorization. That authorization may be
revoked, in writing, at any time, except in limited situations.
___________________________________________________________________________________________________

YOUR RIGHTS – you have the right, subject to certain conditions, to:

• Request restrictions on uses and disclosures of your protected health information for treatment,
payment, or health care operations. However, we are not required to agree to any requested restriction.
Restrictions to which we agree will be documented. Agreements for further restrictions may, however, be
terminated under applicable circumstances (e.g., emergency treatment).
• Confidential communication of protected health information. You can ask us to contact you in a specific
way (for example, home or office phone) or to send mail to a different address. We will arrange for you to
receive protected health information by reasonable alternative means or at alternative locations.
• Inspect and obtain copies of protected health information which is maintained in a designated record
set, except for psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil,
criminal or administrative action or proceeding, or protected health information that is subject to the Clinical
Laboratory Improvements Amendments of 1988 [42 USC 263a and 45 CFR 493 (a)(2)].
SAMPLE

• If you request a copy of your health information, we will provide it upon receipt of a completed
Authorization for Release of Information form, free of charge at the next home visit or within four (4) business
days. If we deny access to protected health information, you will receive a timely, written denial in plain
language that explains the basis for the denial, your review rights, and an explanation to how to exercise
those rights. If we do not maintain the medical record, we will tell you where to request the protected health
information.

• Request to amend protected health information, if you believe that your health information is incorrect or
incomplete. That request may be made as long as the information is maintained by the Agency. A request for
an amendment of records must be made in writing to the agency’s Privacy Officer.
• Receive an accounting of disclosures of protected health information, you can ask for a list
(accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we
shared it with, and why. We will include all the disclosures except for those about treatment, payment, and
health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12
months.
• Receive notice of a Data Breach. You have a right to be notified of an unauthorized Disclosure of your
Protected Health Information (PHI).
• Receive a paper copy of this notice. You or your representative have right to a separate paper copy of this
Notice at any time even if you or your representative have received this Notice previously. To request a copy,
contact the agency’s office at 555-123-4567.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is
your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.