Understanding your Health Record/Information
I, ________________________________ a resident of the Illinois Veterans Home Quincy(IVHQ). As a resident a
record of your stay is made. Typically, this record contains your symptoms, examinations, test results, diagnoses,
treatment, and plans for future care or treatment. This information, often referred to as your health or medical record,
serves as a:
· Basis for planning your care and treatment
· Means of communication among the many health professionals who contribute to your care
· Legal document describing the care you received
· Means by which you or a third-party payer can verify that services billed were actually provided
· A tool in educating health professionals
· A source of data for medical research
· A source of information for public health officials who oversee the delivery of health care in the United States
· A source of data for facility planning and marketing
· A tool with which we can assess and continually work to improve the care we render and the outcome we achieve.
Understanding what is in your record and how your information is used helps you to:
· Assure its accuracy
· Better understand who, what, when, where, and why others may access your health information
· Make more informed decisions when authorizing disclosures to others
Illinois Veterans Home Quincy is required to:
· Maintain the privacy of your health information
· Provide you with a notice as to our legal duties and privacy practices with respect to information we collected and
maintain about you
· Abide by the terms of this notice
· Notify you if we are unable to agree to a requested restriction
· Accommodate reasonable requests you may have to communicate health information by alternative means or at
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide you, your Power of Attorney for Health, Guardian, or other Legal representative contact and/or mail you a revised notice to the address you have supplied us.
We will not use or disclose your health information without your authorization, except as described in this notice.
Your Health Information Rights
Although your health record is the physical property of the Illinois Veterans Home Quincy, the information in the health record belongs to you. You have the following rights:
· You may request a restriction of certain uses of your health information or record for treatment, payment or healthcare operations by completing a Request for Restriction of Use and Disclosure of Health Information. We will consider your request, although we are under no obligation to accept it or to abide by it.
· Obtain a paper copy of our Notice of Privacy Practices upon request
· You may request to inspect and/or obtain copies of your health information, which will be provided to you in the time frames established by law. If you request copies, we will charge you $0.25 per page.
· If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such request must be in writing, and you must provide a reason to support the amendment. We ask that you use the form provided by our facility to make such requests. For a request form, please contact your Social Worker and follow the instructions on the form.
· You may request that we provide you with a written accounting of certain disclosures made by us during the time period for which you request (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our facility. Please note that such an accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment, or health care operations; disclosures made to you or your legal representative, or to any other individual involved with your care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any 12 month period. However, for any requests thereafter, you will be charged a reasonable cost-based fee.
· Request communications of your health information by alternative means (large print) or alternative locations (different address). We will attempt to accommodate all reasonable requests.
· You may revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Examples of Disclosures for Treatment, Payment and Health Operations
We will use your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in
your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. If you are hospitalized, referred to or seek the care of a physician who specializes in a certain aspect of care (such as an orthopedic physician) or are discharged, we will provide your physician or subsequent healthcare provider with copies of various reports that should assist him or her in treating you, if you are discharged from our facility. In some cases, these reports may be transmitted via facsimile (fax) machine.
We will use your health information for payment.
For example: We will use your health information for payment purposes. A bill may be sent to you or a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnoses, procedures, and supplies used. If you are a veteran the Iowa City Veterans Administration Medical Center is notified when you are admitted to the Illinois Veterans Home Quincy. They will receive a copy of your health, financial, and military information on admission. They may audit our records or verify that you are here.
The Veterans Affairs Regional Office is notified of your admittance to the Illinois Veterans Home Quincy. They receive
your health, financial and military information. They may audit our records or verify that you are here anytime during your stay. If you are eligible for Aid and Attendance or Pension from the VA, they may request additional information or request your presence for exam at a VA facility. If your condition changes and/or requires a level of care change, additional information may be required by them.
We will use your health information for health care operations.
We will use your health information for regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.
Other uses and disclosures:
Business associates: There are some services provided in
our organization through contracts with business associates. When these services
we can disclose your health and financial information to these business
associates so they can provide services to you. To protect your health
information, however, we require the business associate to appropriately safeguard your information.
Examples: Auditors, Lawyers, Hospitals, Clinics, Doctors, Dental Services, Physical Therapy and Rehabilitation Centers, Labs, Medical Suppliers, Veterans Administration Facilities, Ambulance Services, Dieticians, Hospice, Hearing Services, Vision Services.
Communication with family: IVH-Q staff and agents, using their best judgment, can disclose to a family member, other relative, close personal friend or any other person you may identify, health information relevant to that person's involvement in your care, payment related to your care, or absence or presence at IVH-Q.
Department of Aging/Ombudsmen: We can disclose your records as required by law to the Ombudsmen or Department of Aging.
Destruction: We can disclose your health record to a reputable firm in the business of destruction of legal records, 6 years after death or discharge from our facility.
Directory: Unless you notify us that you object, we can use your name, location in the facility, and religious affiliation for directory purposes. This information can be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
We can also use your name on a nameplate and your picture in medication book in order to identify you and your room, unless you notify us that you object. We can also request that you wear a wristband containing your name, birth date, resident number (R#), and building, while a resident of IVH-Q for identification purposes.
Electronic transmissions: Your health information will
be transmitted electronically should you require an x-ray, EKG (electrocardiogram)
or a pacemaker check. As your health information may be transmitted via
facsimile (fax) machine
when requested by one of your health care providers, we will take precautionary measures to ensure the privacy of your health information.
Emergency Services: We will disclose your health information for emergency care and treatment
Food and Drug Administration: We can disclose to the FDA
health information relative to adverse events with respect to food, supplements, product
and product defects, or post marketing surveillance information to enable
product recalls, repairs, or replacements.
Fundraising. We might contact you as part of a fund-raising effort on your behalf or to ask you to contribute for a special project or cause.
Funeral homes: We can disclose health information to funeral directors and coroners consistent with applicable law to carry out their duties.
Illinois Department of Veterans Affairs, Springfield, Illinois:
We can use or disclose your records as required by the
Director of our governing agency.
Publications of IVH-Q We can disclose your personal and military information, and picture for publication at the time of admission, and death. We can disclose your name, unit and birthday (excluding year) on our Birthday List in our Activity Calendar.
Law enforcement: We can disclose health information, including your absence or presence from IVH-Q for law enforcement purposes as required by law or in response to a valid subpoena, search warrant, arrest warrant or other bonafide law enforcement duty.
Marketing: We can contact you to provide appointment reminders
or information about treatment alternatives or other
health related benefits and services that can be of interest to you. For marketing purposes, we can use your name,
hometown, photo, or a quotation or other personal information from you.
Notification: We can use or disclose your personal information
to notify or assist in notifying a family member, personal representative,
legal representative, or another person responsible for your care, of
your location and general condition.
If we are unable to reach your family member or personal representative, then we can leave a message for them at the phone number they have provided us.
Organ procurement organizations: Consistent with applicable law, we can disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Public Health: As required by law, we can disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. We can disclose your health information for purposes of licensure.
Personal Services: We can disclose information to companies such as cable, telephone, cellular phones, banks, etc that you or you legal representative request to assist you in obtaining these services.
Pharmacies: We can disclose your health information as
required by law to fill your prescription.
Registries: We can disclose your health information to hospitals, and other related facilities, as required by law. Example: cancer or tumor, hazardous substance exposure.
Reports: Federal law makes provision for your health information
to be released to an appropriate health oversight agency, public health
authority or attorney, provided that a work force member or business associate
believes in good faith that we have engaged in unlawful conduct or have otherwise
violated professional or clinical standards and are potentially endangering one or more residents, workers or the public.
Research: We can disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to assure the privacy of your health information.
Secretary of State: We can disclose your health information
as required by law to the Driver's License Division.
Social Service Agencies: We can disclose your health information for release as required by law or in response to a valid subpoena.
Students: We can use or disclose your health or personal information to students that will be here to assist you. Students will be learning a profession and will be affiliated with recognized schools of learning.
Veteran Organizations and Service Groups: We can use or disclose your name, location in the facility, veteran status, war participation, the year(s) of service, branch of service, religious affiliation, and county at time of admission to the veteran organizations or service groups.
Volunteers and Escort: We can disclose your name, location, and your special conditions.
Voter's Registration: We can disclose your health or personal information to the Adams County Clerk to enable you to vote.
Workers compensation: We can disclose health information
to the extent authorized by and to the extent necessary to comply with
laws, relating to workers compensation or other similar programs established
by law when one of our
employees is injured while providing care to you or if you are injured prior to admittance and are covered by Workers Compensation.
For More Information or to Report a Problem If you have questions and would like additional information, please contact your social worker at Ext. 246.
If you believe your privacy rights have been violated, you can file a complaint with us. These complaints must be filed in writing on a form provided by our facility; within 180 days of the complainant knowing the act occurred. You may also file a complaint with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Acknowledgment: ____________________________________ Date:______________
Resident or Legal Representative