Methodist Children’s Home

Waco, Texas


Health Insurance Portability and Accountability Act (HIPAA)
Guidelines

In all situations, Methodist Children’s Home is committed to providing excellent care for our residents/
clients. Our policy is that all demographic, medical or psychiatric information about those whom we serve is confi dential and to be guarded carefully.

1. Uses and Disclosure of Protected Health Information
The routine ways we use and disclose information is described in this section, which will include but is
not limited to use or disclosure, in order to provide care, treatment and to other medication or medical
equipment. Information about you may be shared with other health care providers in order to provide you with excellent care.

A. Treatment
Our employees and our therapists, counselors, nurses, contract physician and dentist, and other medical
professionals with whom we have contact, will have access to your medical records. These providers
include, but are not limited to pharmacies, hospitals, ambulance drivers or attendants, or specialty
physicians and dentists, and psychologist and psychiatrists. We may send or receive information about
you if you are being admitted to or discharged from this facility or program.

B. Payment
Your protected information will be used as needed to obtain payment for your health care services
as arranged at admission. In some cases additional information may be released in order to approve
payment. Information may be given to a collection agency if required.

C. Health Care Operations
Methodist Children’s Home may use or disclose your protected health information in order to support
the business activities of our organization. These activities include quality assessment and improvement activities, employee review activities, licensing or accreditation surveys or other activities. In the event that this Methodist Children’s Home facility or program is sold, the minimum amount of your protected health information necessary to assure continuity of care will be given to the new owners.

Your protected health information may be used or disclosed in order to provide you with information
about treatment alternatives, or other health related benefits or services.We may use and disclose your protected health information with a third party known as business associates for some activities, such as billings and collections, or for audit or insurance purposes. In these cases, a contract exists between Methodist Children’s Home and the other agency that required careful and confidential management of your information. Business associates are not to disclose our information for activities other than those specified in that contract.

2. Authorizations
Federal law requires written authorization in order to use or disclose your protected health information in some circumstances. This written authorization can be revoked at any time. However, the revocation does not cover information used and disclosed prior to your signature terminating the authorization or to uses or disclosures made in reliance upon the authorization. Authorizations can only be signed by those who have the ability to make their own medical decisions, or those who have legal custody or conservatorship.

A. Psychiatric Notes
Expressed written authorization is required for the release of psychiatric notes, unless the information is needed for treatment, payment or health care operations.

B. Marketing
An authorization is required if we use or disclose your protected health information for marketing
activities. This could include sending information about programs operated by outside agencies and
providers. This may also include contacting the plan sponsor of your individual health plan related to
medical or mental health care for your minor child. Methodist Children’s Home does not allow the sale
of client or resident names to any third party for marketing purposes.

C. Appointment Reminders and Treatment Alternatives
Methodist Children’s Home may send you appointment reminders or information in the following
instances. You can request that we mail these to another address, or send them in or by another format if you desire.

3. Uses and Disclosures that May Occur with Authorization or the Opportunity to Object
Methodist Children’s Home may use and disclose your protected health information in the following
instances. You have the opportunity to agree or object to the use or disclosure of all or part of this
information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then Methodist Children’s Home staff will use their professional judgment to determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health will be disclosed.

A. Others Involved in your Healthcare
Unless you and your conservator object, we may disclose to a member of your family, a relative, a
close friend or any other person you identify, your protected health information that directly relates to
that person’s involvement in your health care. If you are unable to agree or object to such a disclosure,
we may disclose such information as necessary if we determine that it is in your best interest, based on
our professional judgment. We may use or disclose protected health information to notify or assist in
notifying a family member, personal representative or any other person responsible for you about your
current location, general condition or death. Finally we may use or disclose protected health information
to an authorized public entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health.

B. Emergencies
Methodist Children’s Home may use or disclose your protected health information in an emergency
situation. If this happens, Methodist Children’s Home will try to obtain verbal consent as soon as reasonably practical after the delivery of treatment. If our staff is not able to obtain your consent, we
may still use or disclose your protected health information in order to treat you.

C. Communication Barriers
Methodist Children’s Home may use and disclose your protected health information if our staff is
not able to communicate effectively with you due to substantial communication barriers. Methodist
Children’s Home will work to obtain the services of an appropriate translator to assure your
understanding of your situation.

4. Other Permitted and Required Uses and Disclosures that may be Made Without
Your Authorization or Opportunity to Object.
We may disclose your protected health information in the following situations without your consent or
authorization. Many of these reports must be made to comply with other state or federal laws. You will be notifi ed, if required by law. These situations include:

A. Public Health
Methodist Children’s Home may disclose your protected health information for public activities and
purposes to a public health authority that is permitted by law to collect or receive the information. The
disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose
your protected health information, if directed by the public health authority. Certain events such as
birth, death, and certain diseases such as tuberculosis, and public health surveillance activities must
be reported. Methodist Children’s Home may disclose information to a person who may have been
exposed to a disease or may otherwise be at risk of contracting or spreading the disease.

B. Health Oversight
Methodist Children’s Home may disclose protected health information to a health oversight agency for
activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil right laws.

C. Abuse, Neglect or Exploitation
Methodist Children’s Home will disclose protected health information, as required by law to a public
health authority that is authorized by law to receive reports of child abuse or neglect, or the abuse,
neglect or exploitation of the elderly or disabled.

D. Food and Drug Administration (FDA)
Federal law requires that the FDA monitor certain medical equipment, devices and products. Injury
or death related to these products must be reported. Methodist Children’s Home must disclose your
protected health information to a person or company as required by the Food and Drug Administration
to report adverse events, product defects or problems or biologic product deviations. This information
is used to track products; enable product recalls; make repairs or replacements, or to conduct post
marketing surveillance, as required.

E. Legal Proceedings
Methodist Children’s Home may disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or administrative tribunal (to the extent
such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery
request or other lawful process. Methodist Children’s Home may disclose information in order to
defend the agency in a lawsuit.

F. Employers/Workers Compensation
Methodist Children’s Home will use and disclose protected health information if this agency provides
health care to employees at the request of the agency in order to conduct an evaluation of the workplace or to evaluate whether or not the employee has a work related injury. Your information may be disclosed by our staff as authorized to comply with worker’s compensation laws, or investigations and other similar legally established programs.

G. Law Enforcement/National Security
Methodist Children’s Home may also disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal
processes as otherwise required by law, (2) limited information requests for identifi cation and location
purposes (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs in this facility or program, and (6) medical emergency that indicates a crime may have occurred. Your protected health information may be disclosed as required for national security or intelligence activities as required by law.

H. Coroners, Funeral Directors and Organ Donation
Methodist Children’s Home may disclose protected health information to a coroner or medical examiner
for identification purposes, determining the cause of death, or for the coroner or medical examiner
to perform other duties authorized by law. We may also disclose protected health information to a
funeral director to carry out their duties. We may disclose such information in reasonable anticipation
of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue
donation purposes. Funeral directors and cadaver or organ donor centers will only be contacted if your
conservator has fi rst given us specifi c instructions on the proper agency to contact.

I. Research
We may disclose your protected health information to researchers if your conservator agrees in writing
to participate in a study. Participation is always voluntary. If you participate, Methodist Children’s
Home will assure that the research has been approved by an institutional review board that has
reviewed the research proposal and established protocols to ensure the privacy of your protected health
information.

J. Criminal Activity
Consistent with applicable federal and state laws, we may disclose your protected health information,
if we believe that the use or disclosure is necessary to prevent to lessen a serious and imminent threat
to the health or safety of a person or the public. We may also disclose protected health information
if it is necessary for law enforcement authorities to identify or apprehend an individual. If Methodist
Children’s Home is providing counseling or therapy to you to help you stop criminal behavior, we will
not notify law enforcement if you tell our staff, as part of your treatment that you have committed a
violent criminal act.

K. Inmates
We may use or disclose your protected health information if you are an inmate of a correctional facility
and Methodist Children’s Home created or received your protected health information in the course of
providing care to you.

L. Incidental Disclosures
Because most of the children living in Methodist Children’s Home facilities or foster homes participate
in group activities, other residents will come to know your name and perhaps some of your personal
story because of personal relationships, group counseling or therapy sessions. Methodist Children’s
Home will not share your records with other residents in our facilities.

M. Required Uses and Disclosures
Under the law, Methodist Children’s Home must make disclosures to you and when required by the
Secretary of the Department or Health and Human Services to investigate or determine our compliance
with the requirements of Section 164.500 et. Seq.

5. Your Rights
Federal law establishes your right to access and amend your protected health information. The following
instructions tell you how you can exercise these rights. All requests must be made in writing to the Privacy Official listed on the last page, or the President of the agency. Methodist Children’s Home staff will assist you in writing your request if needed. In some cases, your request might be denied. If this happens you can file a grievance or ask that another professional review the record on your behalf.

A. You have the right to inspect and copy your protected health information.
This right will be accommodated within the limits of state law and licensing regulations. Federal law
limits and restricts your access to certain types of records, such as psychotherapy notes.

B. You have the right to request an amendment of your protected health information.
You may request an amendment or correction in your information. The request can ask that Methodist
Children’s Home make the change in your record, or you may insert your own statement into the record.

C. You have the right to receive an accounting of certain disclosures made my Methodist Children’s Home of your protected health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in the Notice of Privacy Practices. Certain exclusions apply.

D. You have the right to request a restriction of your protected health information.
You may ask Methodist Children’s Home not to use or disclose any part of your protected health
information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected healthcare information not be disclosed to family members or friends who may be involved in your care. Please discuss any restrictions you wish to request with the Program
Administrator or Outreach Office Director of your Facility or Program. Methodist Children’s Home will
consider your request, but reserves the right to deny these requests. Any restrictions requested by you
and agreed to by Methodist Children’s Home will be documented in a written agreement.

E. You have the right to receive confidential communications from us by alternative means or at an alternative location.
Methodist Children’s Home will accommodate reasonable requests, but our staff may not agree if it
prevents us from providing excellent care or receiving payment. This can include sending information
to you at an alternative address.

F. You have a right to obtain a paper copy of this notice from us.
Methodist Children’s Home will provide a paper copy of this notice upon admission and any time
signifi cant changes are made. A paper copy will be given if requested, even if you have agreed to accept this notice electronically.

6. Complaints
You may file a complaint if you believe your privacy rights have been violated by Methodist Children’s
Home. You may fi le an internal complaint by notifying the Privacy Offi cial at the address below. You may also call the Privacy Offi cial if you have a question about our complaint process or this Notice. We will not retaliate against you for filing a complaint.

Privacy Official (Sandy Matus)
Methodist Children’s Home
1111 Herring Ave.
Waco, Texas 76708
1-254-753-0181
1-800-964-9226


If you wish to complain directly to the Secretary of Health and Human services, you may file a complaint by writing to the Office of Civil Rights.

Secretary of Health and Human services
200 Independence Ave. S.W.
Washington, D.C. 20201
1-800-368-1019


This notice was published by Methodist Children’s Home and becomes effective on April 14, 2003, on whatever date the agreement is executed by and/or between Methodist Children’s Home and their specific Business Associate(s), whichever is later.