| Upon
notification, review this form: 1) Download the Notice
of Privacy Practices Form Here 2) Read, Sign and 3)
Mail to: Martha Lloyd Community Services
Attn: Admissions
190 West Main Street
Troy, PA 16947
Notice of Privacy Practices This notice describes how health information about you
may be used and disclosed and how you can get access
to this information. Please review this notice carefully. In the course of rendering health care services, Martha
Lloyd Community Services creates, obtains, and/or maintains
health information. Every time you receive a health-related
service from Martha Lloyd Community Services, a record
of your visit is created. Typically, this record contains
information about your general condition, symptoms, examination
and test results, diagnoses, treatment, and a plan for
future care or treatment. This information, often referred
to as your health or medical record, serves as a basis
for planning your care and treatment. This information
is communicated among our staff who contributes to your
care. This information is also used by Martha Lloyd Community
Services to obtain payment for services, for educating
our staff, as a source of data for research, as a source
of information for public health officials charged with
the responsibility for monitoring our organization and
the services it provides, for organization-wide strategic
planning, and to apply for and maintain accreditation. Understanding what is in your medical 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 to
make more informed decisions when you are requested to
authorize disclosure of healthcare information to others. YOUR HEALTH INFORMATION RIGHTS
Although your health record remains the physical property
of Martha Lloyd Community Services, you have access
to the information contained in our records. Access
is defined as the physical review and/or obtaining
a physical copy of health care records. You have numerous
rights when it comes to your health information. You
have the right to request a restriction on certain
uses and disclosures of your information. You also
have the right to inspect and/or obtain a copy of your
healthcare record, but before requesting a copy of
your healthcare record, please inquire whether any
fee will be charged for the reproduction of the information
requested. You have the right to receive an accounting
of certain disclosures of your health information,
and you have the right to receive communications of
your health information by alternative means or to
alternative locations. You have the right to revoke
your authorization to use or disclose health information
except to the extent that use or disclosure has already
been taken. You also have the right to obtain a paper
copy of this Notice A special relationship normally exists between parents
and their minor child affording parental rights to control
and protect health information of their child. Martha
Lloyd Community Services offers parents access to their
minor child's health records unless: 1) an applicable
law prohibits such disclosure; 2) an order from a court
of competent jurisdiction appoints a personal representative
for the minor other than the parents; or, 3) a written
agreement between parents and their minor, furnished
to Martha Lloyd Community Services in advance of any
disclosure, limits access of a parent to a minor's health
information. PROVIDER Responsibilities
We will not disclose your health information without
your consent or authorization, except as described
in this Notice. Martha Lloyd Community Services is
required by law to maintain the privacy of your health
information and to provide you with a notice as to
our legal duties and privacy practices with respect
to the information we collect and maintain about you.
Martha Lloyd Community Services is required to abide
by the terms of this notice, to notify you in writing
if we are unable to agree to a requested restriction
on the use of your health information, and to accommodate
reasonable requests made by you to communicate health
information by alternative means or to alternative
locations. We reserve the right to change our privacy
and disclosure practices at any time and to make the
new provisions effective for all protected health information
we maintain. Should our practices change, we will notify
you in writing. TO REQUEST ASSISTANCE OR TO REPORT A COMPLAINT OR PROBLEM
If you have questions, would like additional information,
or experience a problem, you may contact the Privacy
Officer at 570-297-2185. If you believe your privacy
rights have been violated, you can file a complaint
with the Martha Lloyd Community Services Privacy Officer
or with the United States Secretary of Health and Human
Services, U.S. Department of Health and Human Service,
200 Independence Avenue S. W., Washington, D.C. 20201.
Telephone: (202) 619-0257 or toll free 1-877-696-6775.
You may also contact the United States Office of Civil
Rights at 1- 866-627-7748. There will never be any
type of retaliation for making an inquiry or for filing
a complaint, and you will never be asked to waive your
right to make a complaint or report a problem as a
condition of receiving services from Martha Lloyd Community
Services. EXAMPLES
of Disclosures for Treatment Payment and Healthcare
Operations Where Disclosure or Use May occur Without
Consent or Authorization: The following list of examples is not exhaustive and
may not apply to your situation. If you have a question
or concern, please consult with the Martha Lloyd Community
Services Director of Compliance at 570-297-2185. Treatment: This means that information obtained by a
nurse, physician or other member of the Martha Lloyd
Community Services staff will be recorded in your health
record and used to determine the course of treatment
that should work best for you. Physician orders and notes
from the staff who comply with these orders will be recorded
along with any observations. This practice helps the
healthcare team know how you are responding to the services
outlined in your service plan. Payment: We will use your healthcare information to
prepare, submit and/or process bills to you or a third-party
payer, including Medicare, Medicaid, and other federal,
state or locally- administered program payers. The information
on the bill may include information that identifies you,
as well as your diagnosis, procedures performed and/or
supplies and equipment furnished to you. Maintenance
of Healthcare Operations: Members of our
healthcare staff, the risk or quality improvement manager,
and members of the quality improvement team may use information
in your health record to assess 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 healthcare and services
provided by Martha Lloyd Community Services. Appointment
Reminders: We may contact you to remind
you of a scheduled appointment. Business
Associates: In some instances, we may utilize
external vendors - referred to as "business associates" -
to provide services in support of Martha Lloyd Community
Services operations. When contracting with a business
associate, we may disclose your health information so
the business associate can perform the tasks that we
have asked them to do. We require our business associates
to appropriately safeguard your healthcare information
from further disclosure without your written consent
or authorization. Directory
of Individuals Served: Unless you notify Martha
Lloyd Community Services in writing of your objection,
we will maintain your name and primary service location
in one of our facilities or enrollment in a non-residential
program for directory purposes. The directory is used
for operational purposes. Notification
in Case of Emergency: Unless you notify
Martha Lloyd Community Services in writing of your objection
Martha Lloyd Community Services staff, using its best
judgment, may use or disclose health information about
your general condition and location to notify or assist
in notifying a family member, personal representative,
or another person responsible for your care and welfare. Research: We may disclose your demographic and health
information to researchers when an institutional review
board has reviewed and approved the research proposal,
and established protocols to ensure the privacy of your
health information. Funeral
directors: We may disclose health information
that is consistent with applicable law to funeral directors
so that they may carry out their duties. Organ
Procurement Organizations: Consistent with applicable
law, we may disclose health information to organ procurement
organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose
of tissue donation and transplant. Marketing: We may contact you to provide information
about health-related benefits and services that may be
of interest to you. Fundraising: Fundraising activities are an important
operational component helping Martha Lloyd Community
Services to maintain its successful programs and operations.
Martha Lloyd Community Services, or one of its affiliated
business partners, may solicit you as part of our fundraising
activities. You have the right to have your name removed
from the Martha Lloyd Community Services solicitation
list. You are not obligated to participate or support
any fundraising activity and our services or your employment
status will not be affected in any manner by any decision
to support or receive information regarding and fundraising
activity. If you wish to remove your name from our solicitation
list, please ask a Martha Lloyd Community Services staff
member for assistance. Food
and Drug Administration (FDA): We may disclose
to the FDA health information relative to adverse events
with respect to food, supplements, product and product
defects, or post marketing surveillance information to
enable product recalls, repairs, or replacement. Public
Health: As required by law, we may disclose your
health information to public health or legal authorities
charged with preventing or controlling disease, injury
or disability. Included, as public health disclosures
are any disclosures of your health information as requirement
statutes regarding reportable instances or suspected
Adult or Child abuse or neglect. Court
Orders and Subpoenas: We may disclose your health
information pursuant to any court order or subpoena pertaining
to any purpose defined by statute and as ordered by a
court of competent jurisdiction. Licensing
and Accreditation Organizations: We may disclose
your health information pursuant to licensing and accreditation
activities to maintain the health, safety and welfare
of the people we serve and/or to promote quality outcomes. Correctional
Institution: Should you become an inmate
of a correctional institution or be placed under supervision
of the juvenile or adult criminal court, we may disclose
to the institution or agents thereof, probation or parole
officer or their designees, health information necessary
to preserve or maintain your health and the health and
safety of other individuals. Law
Enforcement: We may disclose health information
for law enforcement purposes as required by law or in
response to a valid subpoena. Federal law also makes
provision for your health information to be released
to an appropriate health oversight agency, public health
authority or attorney, provided that a work force member
or business associate believes, in good faith, that we
have engaged in unlawful conduct or have otherwise violated
professional or clinical standards and are potentially
endangering one or more individuals served, employees
or the public.
Martha Lloyd Community Services
Attn: Admissions
190 West Main Street
Troy, PA 16947
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