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.
This Notice of Privacy
Practices is provided to you as required by the Health Insurance Portability
and Accountability Act (HIPAA). It describes how the Tennessee State Veterans’
Homes Board (TSVHB) and its staff may use or disclose your protected health
information (PHI), with whom that information may be shared and the safeguards
the TSVHB has in place to protect it. This notice also describes your rights to
access and amend your PHI. You have the right to approve or refuse the release
of specific information outside the TSVHB except when the release is required
or authorized by law or regulation.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
You will be asked to
sign an acknowledgement of receipt of this notice. Our intent is to make you
aware of the possible uses and disclosures of your PHI and your privacy rights.
The delivery of your health care services will in no way be conditioned upon
your signed acknowledgement. If you decline to sign an acknowledgement, we will
continue to provide your treatment, and will use and disclose your PHI for
treatment, payment, and health care operations when necessary.
THE TSVHB’S DUTIES TO YOU REGARDING PHI
information” (PHI) is individually identifiable health information. This
information includes your age, address, email address, and relates to your
past, present, or future physical or mental health or condition and related
health care services. The TSVHB is required by law to maintain the privacy of
your PHI; to provide you notice of the TSVHB’s legal duties and privacy
practices related to the use of your PHI, to abide by the terms of the current
notice and communicate any changes in the notice to you, and to notify you if a
breach of unsecured PHI occurs that affects you.
The TSVHB reserves the
right to change this notice. Its effective date is at the end of this notice.
The TSVHB reserves the right to make the revised or changed notice effective
for health information we already have about you as well as any information we
receive in the future. You may obtain a
Notice of Privacy Practices by contacting the TSVH or on the TSVHB website at
HOW THE TSVHB MAY USE OR DISCLOSE YOUR PHI
Required Uses and Disclosures
To You: The TSVHB is required
to disclose your health information to you unless a competent medical authority
has determined that such disclosure would be harmful to you.
To DHHS: The TSVHB is required
to disclose health information to the Secretary of the Department of Health and
Human Services for investigations or determinations of compliance with health
laws related to the protection of your health information.
Uses and Disclosures for Which an Authorization
or Opportunity to Agree or Object is Not
For Treatment: The TSVHB may use and
disclose your PHI to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health
care with a third party such as the Department of Veterans Affairs (VA) or a
physician, medical specialist, therapist, pharmacist, laboratory, or other
health care provider who, at the request of your physician, becomes involved in
your care. In emergencies, the TSVHB will use and disclose your PHI as
necessary to provide the treatment you need.
For Payment: Your PHI will be used
and disclosed as needed to obtain payment for your health care services. For
example, the TSVHB may contact the VA or your health insurer to certify that
you are eligible for benefits and to determine if your treatment is covered.
The TSVHB may also use and disclose your PHI to bill or otherwise obtain
payment from you or third parties who may be responsible for such costs, such
as family members, for services and care provided.
For Health Care
Operations: The TSVHB may use and disclose, as needed, your PHI to support
daily activities related to health care activities including, but not limited
to, quality assessment and improvement activities, medical review, legal
services, and auditing functions, fraud and abuse detection and compliance
programs and investigations, staff or contractor oversight or performance evaluation,
training of nursing and medical students, licensing and credentialing
activities, and other business management and administrative activities. The
TSVHB will share your PHI with third party “business associates” who perform
various activities such as legal services for the TSVHB. The business associate
will also be required to protect your PHI.
When Required by Law: The TSVHB may use or
disclose your PHI if law or regulation requires the use or disclosure.
For Public Health
Activities: The TSVHB may disclose your PHI to a public health authority
that is authorized by law:
· to collect or receive information for the purpose of preventing or
controlling disease, injury or disability, including the reporting of disease,
injury, birth and death, and to conduct public health surveillance,
investigations, and interventions;
· to receive reports of abuse or neglect;
to perform activities related to the quality, safety or
effectiveness of FDA-regulated products or activities, including collecting or
reporting adverse events with respect to food or dietary supplements and
product defects or problems; tracking FDA-regulated products; and enabling
product recalls, repairs, or replacement, or lookback; or
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.
For Health Oversight Activities: The TSVHB may disclose your PHI to a health oversight
agency for activities authorized by law, including audits, investigations,
actions and other activities necessary for the oversight of the health care
system, government benefit programs, other government regulatory programs, and
civil rights laws. Health oversight activity does not include an investigation
or other activity in which you are the subject of the investigation or activity
and the investigation or other activity does not arise out of and is not
directly related to the receipt of health care; a claim for public benefits
related to health; or qualification for, or receipt of, public benefits or
services when a patient's health is integral to the claim for public benefits
For Judicial and Administrative Proceedings: The TSVHB may disclose your PHI during any
judicial or administrative proceeding in response to an order of a court or
administrative tribunal and, in certain conditions, in response to a subpoena,
discovery request, or other lawful process.
For Law Enforcement Purposes: The TSVHB may disclose certain limited PHI to
a law enforcement official for law enforcement purposes pursuant to legal
process such as a court order, subpoena, or summons and as otherwise required
by laws requiring the reporting of wounds and injuries; information requests
for identification and location of a suspect, witness, or missing person;
information pertaining to victims of a crime, deaths that may have resulted
from criminal conduct, crimes occurring on TSVHB property, and medical
emergencies not on TSVHB property believed to result from criminal conduct.
To Coroners, Medical Examiners, and Funeral
Directors: The TSVHB may disclose
your PHI to coroners or medical examiners for the purpose of identification, to
determine cause of death or for the performance of other duties authorized by
law. The TSVHB may also disclose your PHI to funeral directors as necessary to
carry out their duties authorized by law.
For Organ Donation: The TSVHB may use or disclose your PHI for
cadaveric organ, eye, or tissue donations.
For Research Purposes: The TSVHB may disclose your PHI to researchers
when authorized by law, such as when the research has been approved by an
institutional review board that has reviewed the research proposal and
established protocols to ensure the privacy of your PHI.
To Avert a Serious Threat to Health or Safety: The TSVHB may use or disclose certain limited
PHI if the TSVHB believes that its 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. The disclosure must be made to a person reasonably able to prevent or
lessen the threat or necessary for law enforcement authorities to identify or
apprehend an individual.
For Workers Compensation: The TSVHB may disclose your PHI to comply with
workers’ compensation laws and other similar programs.
For Involvement in Your Care and For
Notification Purposes. The TSVHB may disclose to your family member,
other relative, or close personal friend, or any other person you identify, the
PHI directly relevant to that person's involvement with the your health care or
payment related to your health care under the following circumstances. If you
are present for, or otherwise available prior to, a use or disclosure permitted
by this paragraph and have the capacity to make health care decisions, the
TSVHB may use or disclose your PHI if it obtains your agreement; provides you
with the opportunity to object to the disclosure, and you do not express an
objection; or reasonably infers from the circumstances, based on the exercise
of professional judgment, that you do not object to the disclosure. If you are
not present, or the opportunity to agree or object to the use or disclosure
cannot practicably be provided because of your incapacity or an emergency
circumstance, the TSVHB may, in the exercise of professional judgment,
determine whether the disclosure is in your best interests and, if so, disclose
only the PHI that is directly relevant to the person's involvement with your
care or payment related to your health care or needed for notification
purposes. If you have died, the TSVHB may disclose to a family member, or other
persons identified in this paragraph who were involved in your care or payment
for health care prior to your death, your PHI that is relevant to that person's
involvement, unless doing so is inconsistent with any of your prior expressed
preferences known to the TSVHB.
The TSVHB may use or disclose your PHI to notify, or assist in the
notification of (including identifying or locating), your family members,
personal representative, or another person responsible for your care of your
location, general condition, or death under these same circumstances listed
above. In addition, the TSVHB may use or disclose your PHI to a public or
private entity authorized by law or by its charter to assist in disaster relief
efforts, for the purpose of coordinating with such entities the uses or
disclosures permitted by this paragraph.
Uses and Disclosures for Which an Authorization
Except as set forth
above, the TSVHB will only use and disclosure your PHI with your written
authorization or that of your legal representative. You may revoke your
authorization at any time, provided that the revocation is in writing and
except to the extent that the TSVH has acted in reliance on the authorization.
An authorization is specifically required for the following disclosures and
Psychotherapy Notes: The TSVHB must obtain
an authorization for any use or disclosure of psychotherapy notes except for
the originator’s use of the notes for treatment; use or disclosure by the TSVHB
for TSVHB training programs in which students, trainees, or practitioners in
mental health learn under supervision to practice or improve their skills in
group, joint, family, or individual counseling; or use or disclosure by the
TSVHB to defend itself in a legal action or other proceeding; and a use or
disclosure that is required by § 164.502(a)(2)(ii) or permitted by §
164.512(a); §164.512(d) with respect to the oversight of the originator of the
psychotherapy notes; §164.512(g)(1); or § 164.512(j)(1)(i).
Marketing: The TSVHB must obtain
an authorization for any use or disclosure of your PHI for marketing, except if
the communication is in the form of a face-to-face communication made by the
TSVHB to you or a promotional gift of nominal value provided to you by the
Sale of PHI: The TSVHB must obtain an authorization for any
disclosure of your PHI which is a sale of PHI.
YOUR RIGHTS WITH RESPECT TO YOUR PHI AND HOW YOU
MAY EXERCISE THOSE RIGHTS
Your Right to Request Restrictions on Certain
Uses and Disclosures of PHI
Treatment, Payment or
Healthcare Operations. You may request that the TSVHB restrict uses or disclosures of
your PHI to carry out treatment, payment or healthcare operations.
For Involvement in Your
Care and For Notification Purposes. You may request that the TSVHB restrict disclosures of your PHI to
any person you identify for involvement in your care and for notification
purposes, as applicable, regarding your location, general condition or death.
TSVH Agreement to Your
Request. The TSVHB must agree to your request to restrict disclosure of
your PHI to a health plan if the disclosure is for the purpose of carrying out
payment or health care operations and is not otherwise required by law; and the
PHI pertains solely to a health care item or service for which you or a person
other than the health plan on your behalf has paid the TSVHB in full.
Otherwise, the TSVHB is
not required to agree to your request for a restriction on uses or disclosures
of your PHI to carry out treatment, payment or healthcare operations. If the
TSVHB does agree to a restriction on uses or disclosures of your PHI to carry
out treatment, payment, or healthcare operations, then the TSVHB may not use or
disclose your PHI in violation of that restriction. However, if you are in need
of emergency treatment and the restricted PHI is needed to provide emergency
treatment, the TSVHB may use the restricted PHI or disclose that information to
a healthcare provider to provide emergency treatment to you and the TSVHB will
request that the healthcare provider not further use or disclose the restricted
If the TSVHB does agree
to a restriction, that restriction would not prevent uses or disclosures
required by the U.S. Department of Health and Human Services to investigate or
determine the TSVHB’s compliance with the HIPAA privacy regulation; required by
law; for public health activities; about victims of abuse, neglect, or domestic
violence; for health oversight activities; for judicial and administrative
proceedings; for law enforcement purposes; about decedents; for cadaveric
organ, eye or tissue donation purposes; for research purposes; to avert a
serious threat to health or safety; or for workers’ compensation.
If the TSVHB does agree
to a restriction, the TSVHB may terminate that agreement if you agree to or
request the termination in writing; you orally agree to the termination and the
oral agreement is documented; or the TSVHB informs you that the TSVHB is
terminating its agreement to a restriction, except that such termination is
only effective with respect to PHI created or received after the TSVHB has so
Your Right to Receive Confidential
Communications of PHI
The TSVHB will
accommodate any reasonable request you might make to receive communications of
PHI from the TSVHB by alternative means or at alternative locations. The request must be in writing and specify
how or where you wish to be contacted. The TSVHB may also require you to
provide, when appropriate, information as to how payment, if any, will be
handled. You do not need to explain why you are requesting confidential
Your Right to Inspect and to Copy Your PHI
Right of Access. Except for conditions
regarding “Unreviewable Grounds for Denial of Access” and “Reviewable Grounds
for Denial of Access” listed below, you have the right of access to inspect and
to obtain a copy of your PHI maintained by the TSVHB in a designated record
set, for as long as your PHI is maintained in the designated record set, except
for psychotherapy notes or information compiled in reasonable anticipation of,
or for use in, a civil, criminal, or administrative action or proceeding. The
request for access must be made in writing. For purposes of this Notice,
“designated record set” means your medical and billing records maintained by
Unreviewable Grounds for
Denial of Access. The TSVHB may deny you access to your PHI without providing you
an opportunity for review, if the PHI is not something to which you have a
right of access; the PHI is contained in records that are subject to the
federal Privacy Act and your access to it may be denied, if the denial of
access under the Privacy Act would meet the requirements of that law; or the
PHI was obtained from someone other than a health care provider under a promise
of confidentiality and the access you requested would be reasonably likely to
reveal the source of the information.
Reviewable Grounds for
Denial of Access. The TSVHB may deny you access to your PHI if the TSVHB gives you
the right to have such denials reviewed (as required by the Review of a Denial
of Access procedures listed below) and if a licensed health care professional
determines that the access you requested is reasonably likely to endanger the
life or physical safety of you or another person; the PHI makes reference to
another person (unless such other person is a healthcare provider) and a
licensed health care professional determines that the access you requested is
reasonably likely to cause substantial harm to such other person; or the
request for access is made by your personal representative and a licensed
health care professional determines that the provision of access to such
personal representative is reasonably likely to cause substantial harm to your
or to another person.
Review of a Denial of
Access. If the TSVHB denies you access to your PHI on a ground that
qualifies as a Reviewable Ground for Denial of Access, you have the right to
have the denial reviewed by a licensed health care professional who is
designated by the TSVHB to act as a reviewing official and who did not
participate in the original decision to deny access. The TSVHB will promptly
refer a request for review to the designated reviewing official who will,
within a reasonable time, determine whether or not to deny the requested
access. The TSVHB will promptly provide you written notice of the determination
of the designated reviewing official and the TSVHB will carry out the
designated reviewing official’s determination.
Requests for Access and
Timely Action. The TSVHB will act on your request for access to your PHI
maintained by the TSVHB in a designated record set no later than 30 days after
receiving your request. If the TSVHB grants your request, in whole or in part,
the TSVHB will inform you of the acceptance of your request and provide the
access requested in accordance with
the Provision of Access requirements listed below. If the TSVHB denies your
request, in whole or in part, the TSVHB will provide you with a written denial
in accordance with the Denial of Access requirements listed below. If the TSVHB
is unable to meet these requirements within the 30 day time period, the TSVHB
may take up to an additional 30 days (a total of 60 days) for such actions by,
within the first 30 day period, providing you with a written statement of the
reasons for the delay and the date by which the TSVHB will complete action on
your request for access to your PHI.
Provision of Access. If the TSVHB provides you access to your PHI,
in whole or in part, the TSVHB will do so pursuant to the following
The TSVHB will provide you access to the PHI you
requested that is maintain about you by the TSVHB in designated record sets. If
the same PHI that is the subject of a request for access is maintained in more
than one designated record set or in more than one location, the TSVHB will
only produce the PHI once in response to a request for access.
The TSVHB will provide you with access to the
PHI in the form and format you requested if it is readily producible in that
form and format or, if not, in a readable hard copy form or another form and
format upon which we both agree. If this PHI is maintained in one or more
designated record sets electronically and if you request an electronic copy of
that information, the TSVHB will provide you access to the PHI in the
electronic form and format you requested if it is readily producible in that
form and format or, if not, in a readable electronic form and format upon which
we both agree.
The TSVHB may provide you with a summary of the
PHI requested, in lieu of providing you access to your PHI or the TSVHB may
provide an explanation of the PHI to which access has been provided, if you
agree in advance to such a summary or explanation and you agree in advance to
the fees imposed, if any, by the TSVHB for such summary or explanation.
The TSVHB will arrange a convenient time and
place for you to inspect or to obtain a copy of your PHI, or will mail you a
copy of the PHI at your request.
If you request a copy of your PHI or agree to a
summary or explanation of such information, the TSVHB may impose a reasonable,
cost-based fee that includes the cost of labor for copying your PHI, whether in
paper or electronic form; supplies for creating the paper copy or electronic
media if you request the electronic copy be provided on portable media;
postage, when you have requested that the copy, summary or explanation be
mailed; and the fees you agreed to for preparing an explanation or summary of
Denial of Access. If the TSVHB denies you access, in whole or in
part, to your PHI, the TSVHB will, to the extent possible, give you access to
any other of your PHI requested, after excluding the PHI as to which the TSVHB
has a ground to deny you access. The TSVHB will also provide you with a timely,
written denial. In addition, if the TSVHB does not maintain the PHI that is the
subject of your request for access but knows where the requested information is
maintained, the TSVHB will inform you where to direct your request for
Your Right to Amend PHI We Maintain About You
Right to Amend. You have the right to have the TSVHB amend your PHI or a record
about you maintained in a designated record set for as long as the TSVHB
maintains that PHI in the designated record set.
Denial of Amendment. The TSVHB may deny your request for amendment if
the TSVHB determines that the PHI or record that is the subject of the request
was not created by the TSVHB (unless you provide us with a reasonable basis to
believe that the originator of PHI is no longer available to act on the
requested amendment); is not part of the designated record set; would not be
available for inspection under the rights that the HIPAA privacy regulation gives
to individuals to access PHI; or is accurate and complete.
Requests for Amendment and Timely Action. You may request that the TSVHB amend your PHI
maintained by the TSVHB in a designated record set. Your request for amendment
must be made in writing and provide a reason that supports the requested
amendment. The TSVHB will act on your request for an amendment no later than 60
days after receiving your request. If the TSVHB grants your requested
amendment, in whole or in part, the TSVHB will make the appropriate amendment,
inform you that the amendment is accepted, obtain your identification of and
agreement to have the TSVHB notify relevant persons with whom the amendment
needs to be shared, and make reasonable efforts to inform those persons. If the
TSVHB denies your requested amendment, the TSVHB will provide you with a timely
written denial that uses plain language and contains the basis for the denial
of the amendment. The denial notice will also include other information
regarding future disclosures of your PHI and how you may disagree with or
complain about the denial of your requested amendment. If the TSVHB is unable
to act on the requested amendment within 60 days after receiving your request,
the TSVHB may take up to an additional 30 days to act on your request, by,
within 60 days after receiving your request for an amendment, providing you
with a written statement of the reasons for the delay in acting on your request
and the date by which the TSVHB will complete its action on your request.
Actions on Notices of Amendment. When the TSVHB is informed by a healthcare
provider, healthcare clearinghouse or health plan of an amendment to your PHI,
the TSVHB will amend your PHI maintained by the TSVHB in a designated record
set by, at a minimum, identifying the records in the designated record set that
are affected by the amendment and appending or otherwise providing a link to
the location of the amendment.
Your Right to Receive an Accounting of Our
Disclosures of Your PHI
Right to an Accounting of Disclosures of
Personal Health Information. You
have the right to receive an accounting of disclosures of PHI made by the TSVHB
in the 6 years prior to the date of your request for the accounting, except for
To carry out treatment,
payment and health care operations;
Of your PHI made to you;
Incident to a use or
disclosure otherwise permitted or required by the HIPAA privacy regulation;
Pursuant to your
For national security or
To correctional institutions
or law enforcement officials as provided in the HIPAA Privacy regulations;
As part of a limited
data set in accordance with the HIPAA Privacy regulations; or
That occurred prior to
April 14, 2003.
Under some circumstances, the TSVHB may be required
to temporarily suspend your right to receive an accounting of disclosures to a
health oversight agency or law enforcement official.
You may request an accounting of disclosures for
a period of time less than six years from the date of the request.
The accounting must include disclosures of PHI
that occurred during the six years (or such shorter time period as you
requested) prior to the date of the request for an accounting, including
disclosures to or by business associates.
The TSVHB will act on your request for an
accounting, no later than 60 days after receipt of such a request, by providing
you with the accounting requested. If the TSVHB is unable to provide the
accounting within the 60 day period, the TSVHB may extend the time to provide the
accounting by an additional 30 days by providing you, within 60 days of
receiving your request for an accounting, a written statement of the reasons
for the delay and the date by which the TSVHB will provide the accounting.
The TSVHB will provide you the first accounting
that you request in any 12 month period without charge. The TSVHB may impose a
reasonable, cost-based fee for each subsequent request for an accounting that
you request within the 12 month period. The TSVHB will inform you in advance of
the fee and you will have an opportunity to withdraw or modify the request for
a subsequent accounting in order to avoid or reduce the fee.
Your Right to Receive a Paper Copy of This
Notice. You have the right to
obtain a paper copy of this notice from the TSVHB upon request, even if you
have agreed to accept this notice electronically.
Your Right to File a Complaint.
If you think that the
TSVHB has violated your privacy rights, you have the right to file a complaint
with the TSVHB or with the Secretary of the U.S. Department of Health and Human
Services. To file a complaint with the TSVH, please contact: Privacy Officer,
Tennessee State Veterans’ Homes Board, P.O. Box 11328, Murfreesboro,
All complaints must be submitted to the TSVHB in writing. We will not penalize
you nor will we retaliate against you for filing a complaint.
Contact Information. For further information about matters covered by
this notice please contact the Privacy Officer at 1-877-315-1816.
Effective Date. This notice was published and becomes effective
on January 1, 2014.