Methodist Children’s Home

Waco, Texas


Health Insurance Portability and Accountability Act (HIPAA)
Guidelines

Methodist Children’s Home is committed to providing excellent care for our residents/clients. Methodist Children’s Home policy is that all demographic, medical or psychiatric information about those whom we serve is confidential. Under the Health Insurance Portability and Accountability Act (HIPAA), such information, when related to any medical condition, treatment, diagnosis, records, or digitalized or electronic health care information is designated as “Protected Health Information” (PHI).  All such information you provide to Methodist Children’s Home, or which is acquired by Methodist Children’s Home during your association with us, will be preserved as confidential by to the extent required by law, as set out below.
 
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 are not limited to, use or disclosure of PHI, in order to: provide care, follow physician or counseling recommendations for treatment, including medication or medical care, address business and legal needs associated with care, and provide planning for you and any child. Information about you may be shared with other health care providers and viewed by Business Associates of Methodist Children’s Home in the course of duties associated with the care of you and your child. Business Associates of Methodist Children’s Home are those who have executed a Business Associate Agreement (BAA), as provided by HIPAA, with Methodist Children’s Home.

A. Treatment
Methodist Children’s Home employees, therapists, counselors, nurses, contract physician and dentist, other medical professionals with whom we have contact, contractors who supply or facilitate foster care and foster parents, and all our other Business Associates will have access to your medical records. These providers include, but are not limited to, all those persons listed above and pharmacies, hospitals, ambulance drivers or attendants, or specialty physicians and dentists, and psychologist and psychiatrists, teachers, attorneys, employees, business professionals, and Methodist Children’s Home staff personnel and contractors. 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. PHI Disclosure
Methodist Children’s Home may use or disclose your protected health information in order to support
the business activities of our organization as those activities relate to you or your child. These activities include quality assessment and improvement activities, employee review activities, licensing or accreditation surveys or other activities, and the legal aspects of the care of you or your child. In the event that a Methodist Children’s Home facility or program in which you are involved is sold, your PHI and that of your child may be transferred to the new owner(s), upon the execution of one, or more, BAA(s), to provide the basis for continuity of care following transfer of ownership. 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.

D. PHI Security
Your PHI and that of your child will be preserved by double security in an effort to prevent any disclosure which is not intended.  What this means is that Methodist Children’s Home will keep electronic and digitalized records encrypted and secured in electronic form during the time of care associated with you and all records, both in written or tangible form, and digitalized, will be secured behind at least two locking mechanisms against disclosure or use other than as described.

2. Authorizations
Federal law requires written authorization in order to use or disclose your protected health information in some circumstances. These authorizations are signed as part of the onset of the relationship to Methodist Children’s Home and other authorizations may be required of you by Methodist Children’s Home from time-to-time.  This written authorization can be revoked at any time.  However, the revocation does not cover information used and disclosed before 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
You will sign additional written authorization regarding the release of psychiatric records and notes.  Such information related to treatment, payment or health care operations, however, may be released as detailed previously in regard to other medical information.

B. Marketing
An authorization is required if we use or disclose your PHI 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.  You will be contacted should there be a need to address any issue regarding marketing activities and your PHI.

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.  Opportunity to Object
Methodist Children’s Home may use and disclose your PHI 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 PHI relevant to your health will be disclosed.

A. Others Involved in your Healthcare
Unless you object, Methodist Children’s Home may disclose to a member of your family, a relative, a
close friend or any other person you identify, PHI 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.

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. Finally we may use or disclose PHI to any authorized person or public entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health.

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, or your failure to contact us. 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 Further Authorization or Opportunity to Object
We may disclose your protected health information in situations without your consent or authorization in order to comply with state or federal laws.  You will be notified, if required by law. These situations include:

A. Public Health
Methodist Children’s Home may disclose your PHI 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 PHI 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 licensing of Methodist Children’s Home  activities, 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 PHI, 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
PHI 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.

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 in instances in which the agency provides health care to employees in order to facilitate that care, or, in the process of conducting an evaluation of the workplace or to evaluate whether or not the employee has a work related injury. PHI may be disclosed by Methodist Children’s Home staff as authorized to comply with worker’s compensation laws, or investigations and other similar legally established or governmental programs.

G. Law Enforcement/National Security
Methodist Children’s Home may also disclose PHI, 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 identification and location purposes, (3) pertaining to victims of a crime or the investigation 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 or during the time of any program of Methodist Children’s Home, and (6) pursuant to any medical emergency that indicates a crime may have occurred. Your PHI 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 PHI 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. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes when otherwise required or allowed by prior authorization. Funeral directors and cadaver or organ donor centers will only be contacted if your conservator has first given us specific instructions on the donation or the proper agency to contact to facilitate donation.

I. Research
Methodist Children’s Home may disclose your protected health information to researchers if your conservator agrees in writing to participate in a study. Participation in such a study 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 PHI.

J. Criminal Activity
Consistent with applicable federal and state laws and requirements of any applicable licensing agency or its guidelines or rulings, Methodist Children’s Home may disclose your PHI, 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 PHI 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, unless otherwise required by applicable law.

K. Inmates
Upon lawful request, Methodist Children’s Home may use or disclose your PHI if you are an inmate of a correctional facility and Methodist Children’s Home created or received your PHI 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 HIPAA and other applicable federal and state statutes governing the confidentiality and security of your PHI.

5. Your Rights
Federal law establishes your right to access and amend your PHI. The following instructions are intended to advise you how you may 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 PHI
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. Methodist Children’s Home has no control over the records of other medical providers for you whose records may have been provided as part of your connection to Methodist Children’s Home.

B. You have the right to request an amendment of your PHI
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.  In the event you choose to request Methodist Children’s Home to make any such change, that request must be received in writing from you.

C. You have the right to receive an accounting of certain disclosures made my Methodist Children’s Home of your PHI
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in the Notice of Privacy Practices. Certain exclusions, required or provided by law and as described herein, will apply.

D. You have the right to request a restriction of your PHI
You may ask Methodist Children’s Home not to use or disclose any part of your PHI 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 between you and Methodist Children’s Home.  Any other disclosure will be as allowed or required herein.

E. Request confidential communications from us by alternative means or at an alternative location
Methodist Children’s Home will accommodate reasonable requests for alternative communication to alternative addresses or locations for you on written request.  Our staff may not agree if the requested form or place of communication prevents Methodist Children’s Home from providing care or receiving payment.

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

6. Complaints; Written Requests
You may file a complaint if you believe your privacy rights have been violated by Methodist Children’s
Home.  You may also make any written request regarding your PHI or disclosure of your PHI.  You may file an internal complaint or make any written request regarding your PHI through the Privacy Official at the address below. You may also call the Privacy Official if you have a question about our complaint or request process or this Notice. We will not retaliate against you for filing a complaint or for making a written request regarding your PHI.

Privacy Official (Miranda Pena)
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. That contact information is:
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 is a revision of the notice which became first effective on April 14, 2003, and, thereafter, on whatever date any BAA is executed by and/or between Methodist Children’s Home and specific Business Associate(s), whichever is later.