Privacy Act Statement printable pdf download

PRIVACY ACT STATEMENT – HEALTH CARE RECORDS (7/14/2005)

THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.

1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER

(SSN)

Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.

2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

This form provides you the advice required by The Privacy Act of 1974. The personal information will facilitate tracking of

changes in your health and functional status over time for purposes of evaluating and assuring the quality of care provided by

nursing homes that participate in Medicare or Medicaid.

3. ROUTINE USES

The primary use of this information is to aid in the administration of the survey and certification of Medicare/Medicaid long-term

care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory,

reimbursement, policy, and research functions. This system will collect the minimum amount of personal data needed to accomplish

its stated purpose.

The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No.

09-70-1517. Information from this system may be disclosed, under specific circumstances (routine uses), which include: To the

Census Bureau and to: (1) Agency contractors, or consultants who have been engaged by the Agency to assist in accomplishment of

a CMS function, (2) another Federal or State agency, agency of a State government, an agency established by State law, or its fiscal

agent to administer a Federal health program or a Federal/State Medicaid program and to contribute to the accuracy of

reimbursement made for such programs, (3) to Quality Improvement Organizations (QIOs) to perform Title XI or Title XVIII

functions, (4) to insurance companies, underwriters, third party administrators (TPA), employers, self-insurers, group health plans,

health maintenance organizations (HMO) and other groups providing protection against medical expenses to verify eligibility for

coverage or to coordinate benefits with the Medicare program, (5) an individual or organization for a research, evaluation, or

epidemiological project related to the prevention of disease of disability, or the restoration of health, or payment related projects, (6)

to a member of Congress or congressional staff member in response to an inquiry from a constituent, (7) to the Department of

Justice, (8) to a CMS contractor that assists in the administration of a CMS-administered health benefits program or to a grantee of

a CMS-administered grant program, (9) to another Federal agency or to an instrumentality of any governmental jurisdiction that

administers, or that has the authority to investigate potential fraud or abuse in a health benefits program funded in whole or in part

by Federal funds to prevent, deter, and detect fraud and abuse in those programs, (10) to national accrediting organizations, but only

for those facilities that these accredit and that participate in the Medicare program.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF

NOT PROVIDING INFORMATION

For Nursing Home residents residing in a certified Medicare/Medicaid nursing facility the requested information is mandatory

because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of

provided services. If the requested information is not furnished the determination of beneficiary services and resultant

reimbursement may not be possible.

Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of this form will be

furnished to you.

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Signature of Resident or Sponsor

Date

Privacy Act Statement