April 11, 2003

 Dear Council on Aging Client,

 In case we haven’t told you lately, we are glad for the opportunity to provide your services!  In fact, providing you with superior client service is one of our top priorities.

Your privacy is also our top priority.  That is why we want to make sure that you are informed about federal laws that may affect you.   To help you understand these laws, we are sending you the following information about Important Privacy Notices:

 

Please read these notices carefully. If you have any questions, call us at (772) 223-7800. We are available to assist you from 8:00 a.m. until 5:00 p.m., Monday through Friday.

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PROTECTING YOUR PRIVACY

The Council on Aging of Martin County, Inc. strives to protect the personal financial information of current and former clients.

We want you to know that the information you provide is safe and used responsibly.  To maintain the level of service you expect from the Council on Aging, we may need to share limited personal financial information with other service providers that you have requested or require services from, as well as, the Florida Department of Elder Affairs, and the Area Agency on Aging.

You can be certain that protection of your personal financial information is one of our top priorities.

Safeguards in Place at Council on Aging

We use storage technology that protect your sensitive personal information. At the Council on Aging, we have administrative, technical, and physical safeguards in place to ensure privacy. These include:

  

Types of Information We Gather and Use

In administering the Council’s programs and providing services to you, we gather and maintain information that may include nonpublic personal information:

·        From applications, supporting documents, and other forms (e.g., phone/Social Security/ account numbers, income, and employment history).

·        About your transactions with us or our affiliates (e.g., payment history and other account information).

·        From business partners, vendors, and service companies (e.g., payment processing center or credit union).

·        From health-care providers, insurance companies, and third-party administrators (e.g., medical records, claim payment information).

At times, we need to disclose your nonpublic, personal information to our business partners as necessary to affect, administer, or enforce our transactions with you.  We may also share all of this information with companies that perform services on our behalf, provided they contractually agree to keep the information confidential.

In Certain States, You May Be Able to Access and Correct Personal Information

You may have the right to access and correct personal information we have collected about you. Personal information includes information that can identify you (e.g., your name, address, Social Security number, etc.).

 Our Commitment to You

You are a valued client.  We want you to know that the information you provide to us is safe and used responsibly. We’ll continue to maintain your privacy and provide you with information about how we share your non-public personal financial information.

If you have questions about our privacy guidelines, please call us at (772) 223-7800. We are available Monday through Friday from 8:00 a.m. until 5:00 p.m.

PROTECTING YOUR HEALTH INFORMATION

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.

The Council on Aging of Martin County, Inc., affiliates, and subcontractors, responsibly use your individually identifiable health information (referred to as “confidential information”). Confidential information includes information that is created or received by a health-care provider, health plan, employer, or health-care clearinghouse. It also includes information related to your past, present, or future physical/mental health and payment for the provision of your health care.

The Council on Aging may use and/or disclose your confidential information without your authorization for the following purposes:

·        Rating and other activities relating to the placement or renewal of health benefits.

·        Billing, claims payment, review of health-care services, and the management of health-care and related services by health-care providers.

·        Providing appointment reminders or information about treatment alternatives, other health-related benefits, and services.

·        Providing treatment (coordination and management of health-care related services), payment, or health-care operations.

We may also use and/or disclose your confidential information without your authorization as permitted or required by law (e.g., to a public health authority or Food and Drug Administration; or for the purposes of public health intervention or investigation; evaluation relating to the medical surveillance of the work place; work-related illnesses or injuries; civil, administrative, or criminal investigations and/or inspections; judicial and administrative proceedings; local, state, and federal law enforcement purposes). We may also use it for disclosures to the sponsor of a group’s health plan, health insurance issuer, or HMO.

Your authorization is required for the Council on Aging to use your confidential information to determine eligibility for enrollment and continued eligibility under your health plan.  An authorization must also be submitted if you choose to appoint individuals, other than those allowed by law, to receive information about you.  You may revoke the authorization in writing at any time unless we are acting or have acted in reliance on an existing authorization from you.

You have the right to:

·        Request an alternate address or other method of contact if you believe that sending your confidential information to its original location may endanger you.

·        Inspect and copy your confidential information.

·        Request restriction on certain uses or disclosures; however, these restrictions are subject to agreement by the Council on Aging.

·        Receive an accounting of the disclosures we make involving your confidential information.

·        Amend your confidential information (in limited situations).

The Council on Aging will maintain the privacy of confidential information as required by law and by the notice currently in effect. The Council on Aging is also required to provide this notice of our legal duties and privacy practices related to protected health information. This notice is effective April 14, 2003. We reserve the right to make changes or revisions to the terms of this notice and will send you a new notice if any material changes are made.

If you believe your rights have been violated, you may contact the Council on Aging or the secretary of the Department of Health and Human Services.  You will not be penalized for filing a complaint. You may send information to either party at the appropriate address below:

Attn: Privacy Office

Council on Aging of Martin County, Inc.

1071 East 10th Street

Stuart, FL  34996

 

 Department of Health and Human Services

200 Independence Avenue S.W.

Washington, D.C.  20201

You have the right to receive another paper or electronic copy of this notice. To request another copy or to get more information, you may call the Council on Aging at:

(772) 223-7800

We are available Monday through Friday from 8:00 a.m. until 5:00 p.m. 

 

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION FOR CLIENT SERVICE

(Optional Authorization – You are not required to sign)

Please clearly print all information.

 For the purpose(s) of client service and related activities, I hereby agree, on my behalf, that information available regarding coverage or any claim regarding me may be released by the Council on Aging of Martin County, Inc. to me, my spouse, or my legal guardian, my medical providers, my plan sponsors/employers, my agent(s) of record, as applicable, or as may be otherwise lawfully permitted, or as I may further authorize in the box below.

OPTIONAL Additional Authorized Individuals – Please print clearly.

I additionally authorize the following individual(s) to receive the above-named information.

 ________________________________________                 ____________________________________

Full Name (printed clearly)                                                          Relationship to client

 ________________________________________                 ____________________________________

Full Name (printed clearly)                                                          Relationship to client

 

Please Note:  An authorization is not needed for disclosures related to my treatment, the payment for such treatment, or related health-care operations as defined under 45 CFR parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the authorized recipient and may no longer be protected by state or federal law. This authorization does not apply to psychotherapy notes.

 I agree that a photographic copy of this authorization shall be as valid as the original and that this authorization shall expire 15 months after the termination of any coverage I obtain.  I understand that I may request a copy of this authorization. I understand that I may revoke this authorization at any time in writing unless action has been taken in reliance on my authorization. I understand that I may refuse to sign this authorization. Should I choose to sign this authorization, I understand that I have the right to request access to my protected health information that may be used or disclosed.

Information Needed To Identify Your Plan:

Primary Client Social Security Number:            _______-_________-_______

 Primary Client Name Printed Clearly:               __________________________________________________

  _________________________________________________________________________________________

Client Signature                                                                                      Date

 _________________________________________________________________________________________

Spouse Signature (if spouse is covered)                                                   Date

Signature of each Covered Dependents age 18 and over

 ______________________________________                     ____________________________________________

Dependent Signature                              Date                  Dependent Signature                                          Date

 

If signed by a legal representative of client, please indicate the legal representative’s authority to act on behalf of client.

 __________________________________________________________________________________________

Legal Representative Signature                           Authority                                                                 Date

 

For copies of this authorization, call (772) 223-7800. You may fax authorizations to (772) 463-0091 or mail them to Council on Aging of Martin County, Inc., Attn: Privacy Officer, 1071 East 10th Street, Stuart, FL 34996.

 _______________________________________________________________________________________

Group Number                                                                                       Certificate Number

For office use only.