Download 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 attends.
• 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 situations.
• 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).

Special Cases

• 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 disease treatment.
• 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.

Other

• 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 child abuse.

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, please contact:

Name: Ross W. McKinstry, Administrator or Mary Crutchfield, RN, Security/Privacy Officer
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