Instructions For Form Des-1077a - Notice Of Privacy Practices printable pdf download

DES-1077AFOR (11-17)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

NOTICE OF PRIVACY PRACTICES

“This notice describes how medical information about you may be used and disclosed and

how you can get access to this information, please review it carefully”

Effective August 1, 2013

Confidentiality Practices:

The Arizona Department of Economic Security (DES) is committed to protecting your health information. This notice explains how

DES will use, share and protect your health information. It also explains your rights to privacy of your health information as required

by law. If our confidentiality practices change, a new notice will be mailed to you within sixty (60) days of the change.

Uses, Sharing and Protection of Health Information

The law only allows our staff to use your health information when doing their jobs or to share your information when it is necessary to

run the program. When health information is shared with other agencies or organizations, DES requires them to keep your health

information confidential. Your health information will be shared to approve or deny treatment, and to determine if you are getting the

right medical treatment. For example, doctors and nurses employed by the programs may review the treatment plan created for you by

your health care provider to make sure the care you receive is medically necessary.

The Program Will Use and Share Your Health Information Without Authorization to:

•

Make payments to your health care providers for medical services provided to you.

•

Coordinate payment for your care between the program, other health plans, and other insurance companies that may be

responsible for the cost of your care.

•

Coordinate your care between the program, other health plans, and health care providers to improve the quality of your health

care.

•

Evaluate the performance of your health care provider. For example, the program contracts with consultants to review hospital

and other facilities’ medical records to check on the quality of care you received.

•

Release information to its attorneys, accountants, and consultants so that the program is run efficiently and to detect and

prosecute program fraud and abuse.

•

Send you helpful information such as program benefit updates, free medical exams and consumer protection information.

•

Share information with other government agencies or organizations that provide benefits or services when the information is

necessary in order for you to receive those benefits or services.

The Program May Disclose Your Health Information Without Authorization:

•

To public health agencies for activities such as disease control and prevention, problems with medical products or medications.

•

If you are the victim of abuse, neglect or domestic violence.

•

To health oversight agencies responsible for the Medicaid Program such as the U.S. Department of Health and Human Services

and its Office of Civil Rights.

•

In court cases or judicial and administrative hearings when required by law to run the program.

•

To coroners, medical examiners, and funeral directors so they can carry out their jobs as required by law.

•

To organizations involved with organ donation and transplantation, communicable disease registries and cancer registries.

•

To entities authorized to conduct a research project.

•

To prevent a serious threat to a person’s or the public’s health and safety.

•

To the military if you are or have been a member of the armed services.

•

To a correctional facility or law enforcement officials to maintain the health, safety, and security of the corrections systems, if

you are held in custody.

•

To workers’ compensation programs that provide benefits for work-related injuries or illness without regard to fault.

•

To law enforcement or national security and intelligence agencies, and to protect the President and others as required by law.

Uses and Disclosures of Protected Information Based on Your Written Authorization

All other uses and disclosures will be made only with your written authorization. These may include:

•

Most uses and disclosures of your psychotherapy notes will require your authorization

•

Any use or disclosure for marketing purposes will require your authorization.

•

Any use or disclosure that would constitute a sale of your information will require your authorization.

Instructions For Form Des-1077a - Notice Of Privacy Practices

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