THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of your health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; and to abide by the terms of the Notice that are currently in effect.

I.    USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following lists various ways in which we may use or disclose your health information for purposes of treatment, payment and health care operations.

For Treatment.  We will use and disclose your health information in providing you with  services and coordinating your care and may disclose information to other providers involved in your care.  Your health information may be used by doctors involved in your care and by nurses and health aides as well as by physical therapists, pharmacists, suppliers of medical equipment or other persons involved in your care.  For example, we will contact your physician to discuss your plan of care as needed.

For Payment.  We may use and disclose your health information for billing and payment purposes.  We may disclose your health information to your representative, or to an insurance or managed care company, Medicare, Medicaid or another third party payor.  For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for services that will be provided to you.

For Health Care Operations  We may disclose your health information to another entity with which you have or had a relationship if that entity requests your information for certain of its health care operations or health care fraud and abuse detection or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services.

II.  SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following lists various ways in which we may use or disclose your health information.

Individuals Involved in Your Care or Payment for Your Care.  Unless you object, we may disclose health information about you to a family member, close personal friend or other person you identify, including clergy, who is involved in your care.

Emergencies.  We may use or disclose your health information as necessary in emergency treatment situations.

As Required By Law.  We may use or disclose your health information when required by law to do so.

Business AssociatesWe may disclose your protected health information to a contractor or business associate who needs the information to perform services for ThirdAge Services.  Our business associates are committed to preserving the confidentiality of this information.

Public Health Activities.  We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting  abuse or neglect or reporting births and deaths.

Reporting Victims of Abuse, Neglect or Domestic Violence.  If we believe that you have been a victim of abuse, neglect, domestic or other type violence, we may use and disclose your health information to notify a government authority, if authorized by law or if you agree to the report.

Health Oversight Activities.  We may disclose your health information to a health oversight agency for  activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system.

To Avert a Serious Threat to Health or Safety.  When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to someone able to help lessen or prevent the threatened harm.

Judicial and Administrative Proceedings.  We may disclose your health information in response to a court or administrative order.  We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information.  

Law Enforcement.  We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.

Research.  We may use or disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, occurs after your death, or if you authorize the use or disclosure

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations.  We may release your health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

Disaster Relief.  We may disclose health information about you to a disaster relief organization.

Military, Veterans and other Specific Government Functions.  If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities.  We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.

Workers' Compensation.  We may use or disclose your health information to comply with laws relating to workers' compensation or similar programs.

Inmates/Law Enforcement Custody.  If you are under the custody of a law enforcement official or a correctional institution, we may disclose your health information to the institution or official for certain purposes including the health and safety of you and others.

Appointment Reminders.  We may use or disclose health information to remind you about appointments.

Treatment Alternatives and Health-Related Benefits and Services.  We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

III.    USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your health information only with your written Authorization.  You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

IV.    YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your health information.  Each of these rights is subject to certain requirements, limitations and exceptions.  Exercise of these rights may require submitting a written request to ThirdAge Services.  At your request, ThirdAge Services will supply you with the appropriate form to complete.  You have the right to:

Request Restrictions.  You have the right to request restrictions on our use or disclosure of your health information for treatment, payment, or health care operations.  You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.  All requests for restrictions must be made in writing.

We are not required to agree to your requested restriction (except that if you are competent you may restrict disclosures to family members or friends).  If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

Access to Personal Health Information.  You have the right to inspect and obtain a copy of your clinical or billing records or other written information that may be used to make decisions about your care.  Your request  be made in writing or verbally.  In some cases we may charge a reasonable fee for our costs in copying and mailing your requested information.

We may deny your request to inspect or receive copies in certain circumstances.  If you are denied access to health information, in some cases you have a right to request review of the denial.  A licensed health care professional designated by ThirdAge Services who did not participate in the decision to deny would perform this review.

Request Amendment.  You have the right to request amendment of your health information maintained by ThirdAge Services for as long as the information is kept by or for ThirdAge Services.  Your request may be made in writing or verbally, and must state the reason for the requested amendment.

We may deny your request for amendment if the information (a) was not created by ThirdAge Services, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for ThirdAge Services; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determine ThirdAge Services.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

Request an Accounting of Disclosures.  You have the right to request an “accounting” of certain disclosures of your health information.  This is a listing of disclosures made by ThirdAge Services or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosure made pursuant to your Authorization, and certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after our Engagement letter with you, that is within six years from the date of your request.  The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.

Request a Paper Copy of This Notice.  You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically.  You may request a copy of this Notice at any time.  In addition, you may obtain a copy of this Notice at our website, www.Thirdageservices.com

Request Confidential Communications.  You have the right to request that we communicate with you concerning your health matters in a certain manner.  We will accommodate your reasonable requests.  All requests may be made in writing or verbally.

V.     FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact us at our offices at 501 Elm St. Suite 385 Dallas, Texas 75202, or you may call us at (214) 741-4397 or email us through our website, www.Thirdageservices.com.

If you believe that your privacy rights have been violated, you may file a complaint in writing with Third Age Services or with the Office of Civil Rights in the U.S. Department of Health and Human Services.  We will not retaliate against you if you file a complaint.

To file a complaint with Third Age Services, contact us at our offices at 501 Elm St. Suite 385 Dallas, Texas 75202, or you may call us at (214) 741-4397 or email us through our website, www.Thirdageservices.com.

VI.    CHANGES TO THIS NOTICE

We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by Third Age Services as well as for all health information we receive in the future.  We will provide a copy of the revised Notice upon request.

 

 

 

 

 

Summary and Signature Page

I hereby acknowledge that I have been provided a Privacy Notice for ThirdAge Services and understand my rights as a client.

I understand that I have certain rights to restrict the use and disclosure of my Protected Health Information, to obtain a copy of the Notice of Privacy Practices.

Unless I object, my Protected Health Information may be disclosed to assist in notifying a family member, and/or certain other individuals responsible for my care about my location, general condition or my death. My Protected Health Information may also be disclosed to assist in disaster relief efforts.

I understand that other uses of my Protected Health Information will be made only as otherwise authorized by law or with my authorization which I may revoke except to the extent information or actions have already been taken.

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                         Signature                                            Date