Application For Gap Assistance Pharmacy Program For Seniors (Gaps) Page 4
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4RIGHTS AND RESPONSIBILITIES
1.
I know that the information I have given is confidential. I understand that, except as specified
below, information including medical information can be released only for purposes directly related
to the administration of GAPS. At times, the Department of Health and Human Services (DHHS)
will release information to organizations that they hire to carry out specific purposes, but those
organizations will have agreed to be bound by the same guidelines for release of information.
Furthermore, I know that personal health information I provide or that is later gathered by DHHS is
covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and I will be
receiving a Notice of Privacy Practices.
a. I know that any information I have given must be reviewed and verified by DHHS staff. Also, I
understand that I must cooperate fully with state workers if my case is reviewed. No additional
permission by me is needed to get verification or other information.
b. I know that DHHS staff must provide information about my family and me to a computer system
called the State Income and Eligibility Verification System (IEVS). This computer system allows
DHHS to compare the information about my family and me with information from other
agencies, and allows other state (including agencies from other states) and federal agencies to
use information gathered on this application to verify eligibility and determine benefit amounts
for their programs. Other agencies include, but are not limited to, the Internal Revenue Service,
Social Security Administration, and Employment Security Commission, other states’ Medicaid
programs, and the TANF and Food Stamp agency (DSS, in this state). Immigration status will
be verified with the Department of Homeland Security (DHS).
c. I know that, unless I specify otherwise, information about my family and me may be shared by
DHHS for the purpose of making a proper referral of my case to other sources of services or
treatment, in accordance with federal and state law. When possible, I, or my responsible party,
will be asked to agree. However, I further understand that in the case of mandatory reporting,
DHHS must report, and cannot honor my specification to the contrary.
d. I know that, unless I specifically ask not to be included, information about services (including
medical services) provided to my family and me will be stored in a data warehouse operated by
the South Carolina Budget and Control Board, Office of Research and Statistics, and that other
state agencies that provide services to me or my family will be allowed to access that
information in order to be sure that services provided to my family and me are sufficient and
necessary.
2.
I know that my Social Security Number, which I am required to provide, under §1137(a)(1) of the
Social Security Act [42 U.S.C. 1320b-7(a)(1)], may be used or released in connection with the
exceptions in Item 1, above.
3.
I know that according to Federal law and US Department of Health and Human Services (HHS)
policy, DHHS cannot discriminate on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, I should contact HHS by writing to The HHS Director, Office of
Civil Rights, Room 506F, 200 Independence Avenue, SW, Washington, DC 20201 or call (202)
619-0403 (voice) or (202) 619-3257 (TDD). HHS is an equal opportunity provider and employer.
4.
I know that I must report any and all changes in my income, living arrangements, members of the
household, or other information that may affect my eligibility within ten (10) days of the date of the
change(s). I understand that if I fail to notify the department promptly, I may lose benefits and be
subjected to penalties or prosecution.
5.
I know that I may request a hearing if I believe an error has been made in processing my
application.
DHHS Form 942 (January 2010)
Page 4 of 4
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