Patient Notices
HIPAA PRIVACY NOTICE
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.
OUR COMMITMENT TO YOUR PRIVACY
It is our duty to maintain the privacy and confidentiality of your protected health information (PHI). We will create records regarding your and the treatment and service we provide to you. We are required by law to maintain the privacy of your PHI, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the Pharmacy.
As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from our Privacy Officer.
PERMITTED USES AND DISCLOSURES
We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.
· Treatment means providing services as ordered by your practitioner. Treatment also includes coordination and consultations with other health care providers relating to your care and referrals for health care from one health care provider to another. We may also disclose PHI to outside entitles performing other services related to your treatment such as hospital, diagnostic laboratories, home health or hospice agencies, etc.
· Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, prior approval, determinations of eligibility and coverage and other utilization review activities. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release when necessary under applicable law.
· Health care operations means the support functions of the Pharmacy, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to client/patient comments and complaints, practitioner reviews, compliance programs, audits, business planning, development, management and administrative activities. We may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many client/patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you so that others can use the de-identified information to study health care and health care delivery without learning who you are.
OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
We may also use your PHI in the following ways:
· To provide appointment reminders for treatment or medical care.
· To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.
· To disclose to your family or friends or any other individual identified by you to the extent directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.
· When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.
· We will allow your family and friends to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, and similar forms of PHI, when we determine, in our professional judgment, that it is in your best interest to make such disclosures.
We may contact you as part of our fundraising and marketing efforts as permitted by applicable law. You have the right to opt out of receiving such fundraising communications.
· We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all client/patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a client’s/patient’s need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.
· We will use or disclose PHI about you when required to do so by applicable law.
· In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified of these disclosures by your employer, or the Pharmacy as required by applicable law.
Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.
SPECIAL SITUATIONS
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:
· Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.
· Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
· Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.
· Public Health Activities. We may disclose PHI about you for public health activities, including disclosures:
· to prevent or control disease, injury or disability.
· to report births and deaths.
· to report child abuse or neglect.
· to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products.
· to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
· to notify the appropriate government authority if we believe that an adult client/patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the client/patient agrees or when required or authorized by law.
· Health Oversight Activities. We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, and civil rights).
· Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations.
· Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
· In response to a court order, warrant, summons or similar process.
· To identify or locate a suspect, fugitive, material witness, or missing person.
· About the victim of a crime under certain limited circumstances.
· About a death we believe may be the result of criminal conduct.
· About criminal conduct on our premises; or
· In emergency circumstances, to report a crime, the location of the crime or the victims, or the identity, description or location of the person who committed the crime.
* Coroners, Medical Examiners and Funeral Directors. We may release PHI to a coroner or medical examiner. We may also release PHI about client/patients to funeral directors as necessary to carry out their duties and any National Security and Intelligence Activities. We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.
* Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
* Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual.
Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially protected health information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.
OTHER USES OF YOUR HEALTH INFORMATION
Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where appropriate); (b) for marketing purposes; and (c) that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.
YOUR RIGHTS
1. You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.
2. You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to the Privacy Officer.
3. You have the right to inspect and copy the PHI contained in our Pharmacy records, except:
(i) for psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling session and have been separated from the rest of your medical record).
(ii) for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.
(iii) for PHI involving laboratory tests when your access is restricted by law.
(iv) if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you.
(v) if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research.
(vi) for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
(vii) for PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of the information.
In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Medical Records Custodian. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.
We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.
4. You have the right to request an amendment to your PHI, but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:
(i) was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment.
(ii) is not part of your medical or billing records or other records used to make decisions about you.
(iii) is not available for inspection as set forth above; or
(iv) is accurate and complete.
In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to Medical Record Custodian at our Pharmacy, along with a description of the reason for your request.
5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures:
(i) to carry out treatment, payment and health care operations as provided above.
(ii) incidental to a use or disclosure otherwise permitted or required by applicable law.
(iii) pursuant to your written authorization.
(v) to persons involved in your care or for other notification purposes as provided by law.
(vi) for national security or intelligence purposes as provided by law.
(vii) to correctional institutions or law enforcement officials as provided by law.
(viii) as part of a limited data set as provided by law.
To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer at our Pharmacy. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
6. You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.
Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Supplier Standards
1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.
4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
7. A supplier must maintain a physical facility on an appropriate site.
8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours and must maintain a visible sign and posted hours of operation.
9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll-free number available through directory assistance. The exclusive use of mobile communications devices is prohibited.
10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business.
12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items and maintain proof of delivery.
13. A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.
15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.
18. A supplier must not convey or reassign a supplier number i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20. Complaint records must include: the name, address, telephone number, a summary of the complaint, and any actions taken to resolve it.
21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
22. All suppliers of DMEPOS and other items and services must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment for those specific products and services.
23. All DMEPOS suppliers must notify their accreditation organization when a new DMEPOS location is opened. The accreditation organization may accredit the new supplier location for 3 months after it is operational without requiring a new site visit.
24. All DMEPOS supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. An accredited supplier may be denied enrollment, or their enrollment may be revoked, if CMS determines that they are not in compliance with the DMEPOS quality standards.
25. All DMEPOS suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation. If a new product line is added after enrollment, the DMEPOS supplier will be responsible for notifying the accrediting body of the new product so that the DMEPOS supplier can be re-surveyed and accredited for these new products.
26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009
27. A supplier must obtain oxygen from a state- licensed oxygen supplier.
28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f).
29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers.
30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.
JQ Medical Supply, LLC
Client/Patient Bill of Rights and Responsibilites
We believe that all client/patients receiving services from JQ Medical Supply, LLC should be informed of their rights. Therefore, you are entitled to:
1. Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care.
2. Be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible.
3. Receive information about the scope of services that the organization will provide and specific limitations on those services.
4. Participate in the development and periodic revision of the plan of care.
5. Refuse care or treatment after the consequences of refusing care or treatment are fully presented.
6. Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable
7. Have one’s property and person treated with respect, consideration, and recognition of client/patient dignity and individuality.
8. Be able to identify visiting personnel members through proper identification.
9. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client/patient property.
10. Voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal.
11. Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.
12. Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information
13. Be advised on agency’s policies and procedures regarding the disclosure of clinical records.
14. Choose a health care provider, including choosing an attending practitioner, if applicable
15. Receive appropriate care without discrimination in accordance with practitioner orders, if applicable
16. Be informed of any financial benefits when referred to an organization.
17. Be fully informed of one’s responsibilities.
CLIENT/PATIENT RESPONSIBILITIES
1. Client/Patient agrees that rental equipment will be used with reasonable care, not altered or modified, and returned in good condition (normal wear and tear excepted).
2. Client/Patient agrees to promptly report to JQ Medical Supply, LLC any malfunctions or defects in rental equipment so that repair/ replacement can be arranged.
3. Client/Patient agrees to provide JQ Medical Supply, LLC access to all rental equipment for repair/replacement, maintenance, and/or pick-up of the equipment.
4. Client/Patient agrees to use the equipment for the purposes so indicated and in compliance with the practitioner’s prescription.
5. Client/Patient agrees to keep the equipment in their possession and at the address, to which it was delivered unless otherwise authorized by JQ Medical Supply, LLC
6. Client/Patient agrees to notify JQ Medical Supply, LLC of any hospitalization, change in customer insurance, address, telephone number, practitioner, or when the medical need for the rental equipment no longer exists.
7. Client/Patient agrees to request payment of authorized Medicare, Medicaid, or other private insurance benefits are paid directly to JQ Medical Supply, LLC for any services furnished by JQ Medical Supply, LLC.
8. Client/Patient agrees to accept all financial responsibility for home medical equipment furnished by JQ Medical Supply, LLC
9. Client/Patient agrees to pay for the replacement cost of any equipment damaged, destroyed, or lost due to misuse, abuse or neglect.
10. Client/Patient agrees not to modify the rental equipment without the prior consent of JQ Medical Supply, LLC
11. Client/Patient agrees that any authorized modification shall belong to the titleholder of the equipment unless equipment is purchased and paid for in full.
12. Client/Patient agrees that title to the rental equipment and all parts shall remain with JQ Medical Supply, LLC at all times unless equipment is purchased and paid for in full.
13. Client/Patient agrees that JQ Medical Supply, LLC shall not insure or be responsible to the client/patient for any personal injury or property damage related to any equipment; including that caused by use or improper functioning of the equipment; the act or omission of any other third party, or by any criminal act or activity, war, riot, insurrection, fire or act of God.
14. Client/Patient understands that JQ Medical Supply, LLC retains the right to refuse delivery of service to any client/patient at any time.
15. Client/Patient agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.
When the client/patient is unable to make medical or other decisions, the family should be consulted for direction.
All staff members will understand and be able to discuss the Client/Patient Bill of Rights and Responsibilities with the client/patient and caregiver(s). Each staff member will receive training during orientation and attend an annual in-service education class on the Client/Patient Bill of Rights and Responsibilities.
The client/patient and caregiver(s) will also receive a copy of the DMEPOS Supplier Standards, which is included in the Client/Patient Handouts forms.
Grievance Reporting:
I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience. I understand that I may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service. To place a grievance, please call 800-231-6820 and speak to the Customer Services Supervisor. If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the Governing Body. You can expect a written response within 14 working days or receipt.