Notice Of Privacy Practices Acknowledgement

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DSHS Notice of Privacy Practices
for Client Medical Information
Effective September 23, 2013
DSHS must notify you of your Health Information Portability and Accountability Act (HIPAA) privacy rights. (45 CFR
164.520). DSHS is a “hybrid entity.” Not all of DSHS is covered by HIPAA, only the programs listed as
Health Care
Components on the DSHS website
are covered by HIPAA. This notice only applies to clients served by those covered
programs. This notice does not affect your eligibility for DSHS services.
This notice describes how medical information about you may be used and disclosed
and how you can get this information. Please review it carefully.
What is PHI?
Protected Health Information (PHI) is client medical information held by parts of DSHS
covered by HIPAA. PHI is medical information linked to you about your health status or
condition, health care you receive, or payment for your health care. DSHS must protect
your PHI by law.
What PHI does DSHS have
To help us serve you, you may need to give us medical or health information including
about me?
your location, financial information or medical records. We also may get PHI about you
from other sources needed to serve you or pay for your care.
Who sees my PHI?
We see only the smallest amount of PHI we need to do our jobs. We may share PHI with
other programs or persons if allowed by law or permitted by you. For example, your PHI
may be given to and used by the Health Care Authority and other health care providers
to coordinate and pay for your health care. We may share past, current, or future PHI.
We only share your PHI that others need to do their job and as allowed by law. You may
What PHI does DSHS share?
ask for a list of who has seen your PHI for some purposes.
When does DSHS share PHI?
We share PHI on a “need to know basis” to coordinate services and for treatment,
payment, and health care operations. For example, we may share information to decide
if:
• Medical treatment should be provided.
• We can pay for services by health care providers.
• You are eligible for DSHS programs.
• The care you get from providers meets legal standards.
May I see my PHI?
You may see your PHI. If you ask, you will get a copy of your PHI. DSHS may charge
you for copies.
If you think your PHI is wrong, you may ask us to change or add new PHI. You may also
May I change my PHI?
ask that we send any changes to others who have copies of your PHI.
What if someone else needs
You may be asked to sign a form to let us share your PHI if:
my PHI?
• We need your permission to provide services or care;
• You want us to send your PHI to another agency or provider for reasons not allowed
by law without your permission;
• You want PHI sent to someone else, such as your attorney, a relative or other
representative.
Your permission to share your PHI is good until the end date you put on the form. We
can only share the PHI you list. You may cancel or change this permission by writing to
DSHS
DSHS 03-387 (REV. 04/2014)

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