an Authorization for Release of Information Form
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.
Uses and Disclosures: We will use and disclose element
of your protected health information (PHI) in the following ways:
Without your signed authorization
- Treatment: We will send records to the physician
or other health care professional directly involved with your care.
An example would be lab results obtained with a physician's order would
mean that both the physician and our records might contain the results
of our laboratory report. Another example would be childhood immunizations
We will maintain a record of the immunizations we give, but we might
also send the information to your physician or the school your child
- Payment: We will send required information to payment
sources such as insurance companies, Medicare, or Medicaid so that we
may get paid on your behalf.
- Health care operations: We may be required to send
some information for example to the Missouri Department of Health and
Senior Services or Centers For Disease Control and Prevention to assist
with your care. We may also submit information for statistical reporting
or fro auditing purposes to entities that require us to do so by contract.
- When a release is required by law, including in
judicial settings and to health oversight regulatory agencies and law
enforcement. This would include cases of suspected child abuse, where
the investigating agency or the prosecuting attorney requires the release
of information in the interest of child protection.
- In emergency situation or to avert serious health/safety
- To medical examiners, coroners or funeral directors
to aid in identifying you or to help them in performing their duties.
- To organ, tissue, and other donations organization,
upon or proximate to your death, if we have no indication on hand about
your donation preferences (or a positive indication).
- To contact you about appointment reminders, treatment
alternatives and other health related benefits and services.
- In fundraising for ourselves.
- To the sponsor of your health plan.
- We may not disclose PHI to parent of minor children
(under 18 years of age) when the minor does not request it for reasons
of pregnancy, drug abuse and drug abuse treatment, and sexually transmitted
- If we are are not sure if the client wants the PHI
released we will not release the information without a court order.
This might happen when the client is deceased or when there is a dispute
over treatment as, for example, when divorced parents are disputing
over custody rights of children. Any time we feel the agency could be
put into the middle of a dispute for releasing information, we may request
a court order to protect the agency from one party or another. A personal
representative of the client should present a court ordered document
appointing that person as the personal representative.
- All other uses and disclosure by us will require
us to obtain from you a written authorization in addition to any other
permission you will provide us.
Your rights: You have the following rights concerning your PHI:
Restrictions: To request restricted access to all or part of
your PHI. To do this, you must file the appropriate forms to request
us not to release the PHI. We are not required to grant your request.
Confidential Communications: To received correspondence of confidential
information by alternate means or location. To do this, you must five
us appropriate instructions in writing as to how your want to be contacted.
We will do everything in our power to accommodate your wishes; however,
if we must contact you we may do so regardless of your wishes. An example
of this would be a minor child who comes to the health department to
get birth control. We may do testing during the visit that requires
follow up. If we cannot reach you or your do not respond to our request
for a return visit, we will take the necessary steps to reach you so
that you get the treatment you must have.
Access: To inspect or receive copies of your protected health
information. To do this, fill out the written request, submit with any
appropriate fees and we will release your PHI within a reasonable time.
Amendments: To request changes be made to your PHI. To do this,
submit your request in writing and explain why you think a change is
warranted. We are not required to grant your request. Certain information
may not be changed and we will decide what is appropriate.
Accounting: You may receive an accounting of the disclosures
by us of your PHI in the six years prior to your request. To do this,
notify us in writing of your wish. There is no charge for the accounting
of disclosures for one request per year. There are certain disclosures
that are not required to be made to you and these include any disclosures
for Treatment, Payment, or Health Care Operations. We also may not account
for any disclosures of PHI made in conjunction with a Hotline call to
the Missouri Department of Social Services for reports of suspected
This notice: You may get updates or re-issuance of this notice,
at your request. We may update this information from time to time and
will have updated copies available upon request. You may also get the
current copy of the Notice of Privacy on our website at www.randolphcountyhealth.org.
We will abide by our most current Notice Of Privacy.
Complaints: You may complain to us or the U.S. Department of
Health & Human Services if you feel your privacy rights have been
violated. To register a complaint with us, contact the Randolph County
Health Department Administrator or the Security and Privacy Officer
for the department at the address or telephone below. The law forbids
us from taking retaliatory action against you if you complain.
Our duties: We are required by law to maintain the privacy of
your PHI. We must abide by the terms of this notice or any update of this
notice. This notice may change from time to time.
Primary Contact: For more information about our privacy practices,
Name: Ross W. McKinstry, Administrator or Mary Crutchfield, RN, Security/Privacy
Phone: 660-263-6643 Extension 3005
Address: PO Box 488, 423 E. Logan Street, Moberly Missouri 65270
Effective Date: This notice is effective 01/01/03