Shelby County Board of MR/DD
Effective:
April 14, 2003
This
notice describes how personal information about you may be used and disclosed
and how you can get access to this information.
PRIVACY NOTICE TABLE OF CONTENTS
Section II ~ HOW WE USE YOUR PERSONAL INFORMATION
Section III ~ OTHER SERVICES WE PROVIDE
Section IV ~ SHARING YOUR PERSONAL INFORMATION
Section
V ~ OUR
PRIVACY RESPONSIBILITIES
Section
VI ~ YOUR
INDIVIDUAL RIGHTS
Section
VII ~ OUR
ORGANIZATION
Section IX ~ APPENDIX - Printable Privacy Notice and Acknowledgment Form
The Shelby County Board of MR/DD understands that your personal information needs to be kept private. Protecting your personal information is important. We follow strict federal and state laws that require us to keep your personal information confidential.
II. HOW WE USE YOUR PERSONAL INFORMATION
When you receive
services from the MR/DD Board, we may use your personal information for
activities such as: providing you
with services, billing for services, and conducting our normal board business
known as health care operations.
If you have
chosen a personal representative and have agreed to let your personal
representative obtain your personal information, we will provide the information
to your personal representative. If
you have a guardian we will provide the information to your guardian.
Examples
of how we use your information include:
Treatment - We keep records of the care and services provided
to you within the MR/DD Board. For
example, your service and support administrator keeps notes on all contacts made
in coordinating and arranging for services. If you see a nurse working for the MR/DD Board, the nurse
will keep records of any care you receive.
MR/DD Board staff may share your personal information while helping to
develop your service plan.
If MR/DD Board
staff want to share your personal information with anyone who is not employed by
the MR/DD Board, you must give them written permission first.
Some personal
records including confidential communications with a mental health professional,
and substance abuse records, may have additional restrictions for use and
disclosure under state and federal law.
Payment – We keep records that
include payment information and documentation of the services provided to you.
Your information may be used to obtain payment for your services from Medicaid,
insurance, or other sources. For
example, we may disclose personal information about the services provided to you
to confirm your eligibility for Medicaid and to obtain payment from Medicaid.
The MR/DD Board may use your personal information to determine the amount
and type of Medicaid services you need and send this information to the proper
State Department.
Health Care Operations – We use personal information to
improve the quality of care, train staff, manage costs, conduct required
business duties, and make plans to better serve you and other individuals
enrolled in the MR/DD Board. For example, we may use your personal
information to evaluate the quality of treatment and services provided by our
service staff.
III.
OTHER
SERVICES WE PROVIDE
We
may also use your personal information to:
Determine whether you are
eligible for services from the MR/DD Board
Recommend to you service
alternatives and other possible benefits
Tell you about other
service providers who may be able to help you
Remind you of an
appointment unless you tell the MR/DD Board staff that you do not wish to be
reminded
To allow the MR/DD Board
to review direct service contracts
Allow local, state, and
federal agencies to monitor your services
To investigate incidents affecting health and safety, to report these kind of incidents, and to take steps to protect your health and safety
To allow the MR/DD Board
to prepare reports required by the Ohio Department of Mental Retardation
& Developmental Disabilities and
the Ohio Department of Job and Family Services
Contact you for assistance
in passing levies, unless you notify the MR/DD Board that you do not wish to
be contacted for these purposes
IV. SHARING YOUR PERSONAL INFORMATION
There are
limited situations when we are permitted or required to disclose personal
information without your signed authorization. These situations are:
To
protect victims of abuse, neglect, or domestic violence
To reduce or prevent a serious
threat to public health and safety
For health oversight activities such
as investigations, audits, and inspections
For lawsuits and similar proceedings
For public health purposes such as
reporting communicable diseases, work-related illnesses, or other diseases
and injuries permitted by law; reporting births and deaths, and reporting
reactions to drugs and problems with medical devices.
When required by law
When requested by law enforcement as
required by law or court order
To coroners, medical examiners, and
funeral directors
For organ and tissue donation
For workers’ compensation or other
similar programs if you are injured at work and are covered by workers’
compensation or other similar programs
For specialized government functions
such as intelligence and national security
All other uses and disclosures not described in this notice require your signed authorization. You may revoke your authorization at any time with a written statement.
V.
OUR
PRIVACY RESPONSIBILITIES
The
Shelby County Board of MR/DD is required by law to:
Maintain the privacy of
your personal information
Provide this notice
that describes the ways we may use and share your personal information
Follow the terms of
the notice currently in effect
We
reserve the right to make changes to this notice at any time and make the new
privacy practices effective for all information we maintain.
Current notices will be posted and available in the MR/DD Board facilities. You may also request a copy of any notice from the MR/DD Board Privacy Office or by e-mail request to: privacynotice@shelbymrdd.org
You have the
right to:
Request restrictions on
how we use and share your personal information. We will consider all
requests for restrictions carefully but are not required to agree to any
restriction.*
Request that we use a
specific telephone number or address to communicate with you.
Inspect and copy your
personal information including service, and medical and billing records.
Fees may apply.*
Request corrections or
additions to your personal information. You must give the reasons for
wanting the change.*
Request an accounting of
certain disclosures of your personal information made by us. Your request
must state the period of time desired for the accounting, which must be
within the six years prior to your request. The first accounting is free but
a fee will apply if more than one request is made in a 12-month period.*
Request a paper copy of
this notice even if you agree to receive it electronically.
This notice describes the privacy
practices of the Shelby County Board of MR/DD (the MR/DD Board).
This notice also describes the privacy practices of persons or entities
which have signed a contract with the MR/DD Board, which are acting as business
associates and have promised to follow the same rules of confidentiality.
The
MR/DD Board includes:
S&H Products
Shelby Hills Early Childhood Center
Wee School
Wilma Valentine Creative Learning Center
as well as
the MR/DD Board employees and volunteers at those facilities.
If you want to know about the privacy practices of service providers who are not employed by the MR/DD Board and who are not business associates, you should contact them directly.
If you would like further information about your privacy rights or the practices described in this notice, are concerned that your privacy rights have been violated, or disagree with a decision that we made about access to your personal information, please contact us at:
Shelby
County Board of MR/DD
Phone:
(937)
497-8155
Kristi
L. Marcum, Business Manager
e-mail:
kmarcum@shelbymrdd.org
1200
S. Children’s Home Road,
P.O. Box 925
Sidney,
OH 45365
We will
investigate all complaints and will not retaliate against you for filing a
complaint.
You also may
file a written complaint with either:
• The Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775
or
• The Office for Civil Rights, U.S. Department of Health and Human Services at 200 Independence Avenue SW, Room 509F, HHH Building, Washington D.C., 20201 or call OCR’s hotline – voice at 1-800-368-1019, or e-mail at ocrmail@hhs.gov.
If you have already received a copy of the Privacy Notice and need to return your signed Acknowledgment of Receipt of Notice, please mail it to our SCBMR/DD address above--click here.
If you would like to print the Privacy Notice and fill out your Acknowledgment form to send in, please click on the links below:
Privacy Notice ~ Acknowledgement Form