April 14, 2003




Understanding Your Health Record/Information

Each time you visit a provider, a record of your visit is made. Typically, this record contains your diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical care record, serves as a:


·   basis for planning your care or treatment

·   means of communication among the many health professionals who contribute to your care

·   legal document describing the care you received

·   means by which you or a third-party payer can verify that services billed were actually provided

·   a tool in educating health professionals

·   a source of data for medical research

·   a source of information for public health officials who oversee the delivery of health care in the United States

·   a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosures to others.


 Our Responsibilities

The Forest Warren Human Services is required to:

·   maintain the privacy of your health information

·   abide by the terms of this Notice

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post a copy of the revisions at our place of business. This notice becomes effective April 14, 2003.

We will not use or disclose your health information without your authorization, except as described in this notice.


How We Will Use or Disclose Your Protected Health Information


·  Treatment:  We will use your health information for treatment without your consent. For example, information obtained by a therapist, case manager, or other member of your health care team will be recorded in your record and used to course of treatment that should work best for you. Your health care professional, therapist, or case manager will document in your record the expectations of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the health care professional, therapist, or case manager will know you are responding to treatment. We will also provide your healthcare provider with copies of various reports that should assist in treating you once you are discharged from our agency.


·  Payment:  We will use your health information for payment without your consent from the third-party payer you designate, including Medicare, and Medicaid. The information on or accompanying the bill will be limited to that information necessary to establish the claims for which reimbursement is sought. For example, the bill may include information of the dates, types and costs of therapies and services, and a general description of the general purpose of each treatment session or service.


·  Health care operations:  We will use your health information for regular health care operations without your consent. For example, members of the staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to access the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care we provide.


·  Notification:  Using our professional judgment, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible your care of your location, and general condition.


·  Communication with family:  With your written permission, we may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care.


·  Research:  We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.


·  The County administrator:  Without your consent we are permitted to share certain of your Protected Health Information, (PHI), with the County Administrator who is responsible for overseeing this agency and must receive information regarding the operation of this facility as required in certain circumstances as permitted by law.


·  Commitment proceedings:  During the course of an involuntary commitment proceeding, the court may direct that it or a mental health review officer, as allowed under the Mental Health Procedures Act have access to your PHI for purposes of conducting the hearing without your consent. Also, information will be disclosed without your consent to legal counsel assigned to represent you if you are the subject of an involuntary commitment proceeding.


·  Public health:  As required by law, we may disclose your health information without your consent to the public health or legal authorities charged with preventing or controlling disease, injury, or disability.


·  Coroner, medical examiner:  We may disclose your medical information to a coroner and/or a medical director who is investigating the cause of your death.


·  Correctional institution:  Should you be an inmate of a correctional institution, we may disclose to the health care professionals at the institution, without your consent, health information necessary for your health treatment.


·  Required by law:  As required by law, we may use and disclose your health care information. Examples of this type of disclosure may include activities such as a child abuse investigation, older adult abuse investigations, mental health crisis information, grievances by a Drug and Alcohol treatment consumer.


·  Health oversight activities:  Without your consent we may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.



·  Worker’s compensation:  Without your consent we may disclose your health information as necessary to comply with worker’s compensation laws.


·  Marketing:  We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.

Your Health Information Rights

Although your health record is the physical property of the provider, the information in your record belongs to you. You have the following rights:


·  You may request that we not use or disclose your health information for a particular reason related to treatment, payment, or general health care operations, and/or to a personal representative or guardian. We ask that such requests be made in writing on a form provided by our agency. Although we will consider your request, please be aware that we may not be under any obligation to abide by your request.


·  If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by an alternative means or at an alternative location. Such a request must be made in writing, and submitted to our Privacy Officer at the following address:


Health Information Privacy Officer

285 Hospital Drive

Warren, PA  16365

(814) 726-2100


·  We will attempt to accommodate all reasonable requests. Costs incurred in meeting your request may be passed on to you for reimbursement.


·  You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. If you request copies we will charge you a reasonable fee.


·  If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be in writing, and must provide a reason to support the amendment. We ask that you use the form provided by our agency to make such requests. For a copy please contact the Privacy Officer.


·  You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed six years prior to the date of the request). We ask that such requests be made in writing. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for the purpose of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. The accounting of disclosed protected health information will not include disclosures which you have authorized. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.


·  You have the right to obtain a paper copy of our Notice of Information Practices upon request.


·  You may revoke an authorization to use or disclose health information. Except that action has already been taken. Such a request must be made in writing.

For more Information or to Report a Problem

If you have questions and would like additional information, you may contact our agency’s Privacy Officer at:

Health Information Privacy Officer

285 Hospital Drive

Warren, PA 16365

(814) 726-2100

If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by our agency. The complaint form can be obtained from the Privacy Officer, and when completed should be returned to him. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services

Office of Civil Rights

Hubert H. Humphrey Bldg.

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, D.C. 20201


There will be no retaliation for filing a complaint.












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