HIPAA ACKNOWLEDGEMENT

M & M HOME CARE HIPAA POLICY

It is our legal responsibility to protect the privacy of patients and ensure confidentiality of patient information

Starting 4/14/03, medical facilities are required to:
1. Provide each patient with a "Notice of Privacy Practices” regarding the use and disclosure of medical information and their rights with respect to this information

2. Patient must acknowledge in writing the receipt of this information

3. Notice of privacy practices must be clearly posted and copies must be available upon request

4. These forms should be included in each new admission packet

5. Policy and procedures regarding this should be in each facility

What is considered "Protected Health information" (PHI)?

Examples of PHI:
- Names, addresses
- Dates of birth, admission, discharge, death
- Telephone or fax numbers, e-mail addresses
- Social security numbers, medical record or account numbers
- Health plan numbers
- Certificate of license numbers, vehicle numbers, serial numbers
- Biometric identifiers, including finger and voice prints
- Full face photos and any comparable images
- Any other unique ID number, characteristic, or code
- All information in the patient's medical record
- Any information discussed about a patient
- Any patient billing information

Generally, if the patient has been given a copy of the Notice of Privacy Practices, the patient's PHI can be used or disclosed without a patient's authorization to carry out patient treatment, payment, or for other health care operations. Restriction may apply to information related to communicable disease, treatment of drug and alcohol abuse, and research. An authorization is required for the use or disclosure of psychotherapy notes unless the following applies:

1. Can be used by the originator of the notes for treatment

2. For facility mental health training programs of practitioners or students

3. A facility's defense in legal action

4. Can be released to US Dept of Health, coroners or medical examiners, or to avert serious threats to health and safety

HIPAA regulations permit disclosure of a patient's PHI to their family members, other relative or friend involved in the patient's care. Information disclosed should only be related to that person's involvement. Although not required, a verbal agreement from the patient s best in this situation.

Patients have the right to inspect and copy their PHI. Any other person should be referred to the medical records department. When healthcare providers discuss PHI, they must take precautions to avoid others from hearing your conversations. You are permitted to discuss PHI at nurses’ stations and treatment areas, over the phone, in a semi-private room, during rounds with a physician, at a pharmacy counter — BUT lower your voice and talk apart from others when possible.

PROTECT WRITTEN PHI FROM UNINTENTIONAL DISCLOSURE
- Place in cabinets or closed file cabinets
- Restrict electronic transmissions to job related duties
- Dispose of PHI documents according to policy (ie: shredding)

Patient rights in regards to HIPAA:

- Patients may authorize others to inspect their PHI that do not relate to treatment, payment, health care operations and that are not required by law
- Patients have a right to amend their PHI and make restrictions on its use
- Patients have a right to receive an accounting of all disclosures made of their PHI
- Patients may file a complaint if they believe their rights have been violated—fines and penalties may apply, up to $250,000 and imprisonment

I have read and understand all of the above information. I have had the opportunity to have all my questions answered and agree to comply with HIPAA regulation to
the best of my ability

ELECTRONIC SIGNATURE
By selecting the "SUBMIT" button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as your "E-Signature") is the legal equivalent of your manual/handwritten signature on this Agreement.

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.