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NOTICE OF PRIVACY PRACTICES
EFFECTIVE: APRIL 14, 2003
THIS NOTICE DESCRIBES HOW PERSONAL INFORMATION ABOUT
INDIVIDUALS ENROLLED IN OUR PROGRAMS MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY!
PRIVACY PROMISE
The Greene County Board of Mental Retardation and
Developmental Disabilities 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.
HOW WE USE YOUR PERSONAL INFORMATION
When you receive services from the MR/DD Board, we may use your personal
information for such activities as providing you with services, billing for
services, and conducting our normal board business.
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 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.
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, federal agencies to monitor your services
- To investigate incidents affecting health and safety, to report these kinds
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 and 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
MORE INFORMATION
For more information about the practices and rights described in this notice:
- Contact the MR/DD Board at (937) 562-6500 or 245 Valley Road, Xenia, Ohio 45385
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, 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.
YOUR INDIVIDUAL RIGHTS
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, 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.
Requests marked with a star (* ) must be made in writing. Contact the MR/DD
Board for the appropriate form for your request.
OUR PRIVACY RESPONSIBILITIES
The MR/DD Board 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
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- 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 in the MR/DD Board facilities. You may also
request a copy of any notice from the MR/DD Board.
OUR ORGANIZATION
This notice describes the privacy practices of the Greene 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 and which
are acting as business associates, and have promised to follow the same rules
of confidentiality.
The MR/DD Board includes
Greene, Inc., Four Oaks Early Intervention, Homecroft, Inc., Community
Services, the Administration as well as 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.
Contact Us
If you would like further information about your privacy rights, are
concerned that your privacy rights have been violated, or disagree with a
decision that we made about access to your personal information:
Contact the MR/DD Board:
John LaRock, Superintendent
Greene County Board of MR/DD
245 Valley Road
Xenia, Ohio 45385
(937) 562-6500
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.
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
www.ocrmail@hhs.gov.
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