PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
This statement gives you notice required by law (the Privacy Act of 1974). This statement is not a consent form. It will not be used to release or to use your health care information.
I. Authority for collection of your information, including your social security number, and whether or not you are required to provide information for this assessment. Sections 1102(a), 1154, 1861(z), 1864, 1865, 1866, 1871, 1886(j) of the Social Security Act. Medicare participating inpatient rehabilitation facilities must do a complete assessment that accurately reflects your current clinical status and includes information that can be used to show your progress toward your rehabilitation goals. The inpatient rehabilitation facility must use the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IFR-PAI) as part of that assessment, when evaluating your clinical status. The IRF-PAI must be used to assess every Medicare Part A fee-for-service inpatient, and it may be used to assess other types of inpatients. This information will be used by the Centers for Medicare & Medicaid Services (CMS) to be sure that the inpatient rehabilitation facility is paid appropriately for the services that they furnish you, and to help evaluate that the inpatient rehabilitation facility meets quality standards and gives appropriate health care to its patients. You have the right to refuse to provide information to the inpatient rehabilitation facility for the assessment. Information provided to the federal government for this assessment is protected under the Federal Privacy Act of 1974 and the IRF-PAI System of Records. You have the right to see, copy, review, and request correction of inaccurate or missing personal health information in the IRF-PAI System of Records.
II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED The information collected will be entered into the IRF-PAI System No. 09-70-1518. Your health care information in the IRF-PAI System of Records will be used for the following purposes: • support the IRF prospective payment system (PPS) for payment of the IRF Medicare Part A fee-for-services furnished by the IRF to Medicare beneficiaries; • help validate and refine the Medicare IRF-PPS • study and help ensure the quality of care provided by IRFs; • enable CMS and its agents to provide IRFs with data for their quality assurance and ultimately quality improvement activities; • support agencies of the State government , deeming organizations or accrediting agencies to determine, evaluate and assess overall effectiveness and quality of IRF services provided in the State; • provide information to consumers to allow them to make better informed selections of providers; • support regulatory and policy functions performed within the IRF or by a contractor or consultant; 1 • support constituent requests made to a Congressional representative; • support litigation involving the facility; • support research on the utilization and quality of inpatient rehabilitation services; as well as, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health for understanding and improving payment systems.
III. ROUTINE USES These “routine uses” specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the IRF-PAI System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of protected health information authorized by these routine uses may be made only if, and as, permitted or required by the ‘Standards for Privacy of Individually Identifiable Health Information.’ (45 CFR Parts 160 and 164). Disclosures of the information may be to:
IV. EFFECT ON YOU IF YOU DO NOT PROVIDE INFORMATION The inpatient rehabilitation facility needs the information contained in the IRF-PAI in order to comply with the Medicare regulations. Your inpatient rehabilitation facility will also use the IRF-PAI to assist in providing you with quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect 3 information also could make it difficult to evaluate if the facility is giving you quality services. If you choose not to provide information, there is no federal requirement for the inpatient rehabilitation facility to refuse you services.
CONTACT INFORMATION
If you want to ask the Centers for Medicare & Medicaid Services to see, review, copy or request correction of inaccurate or missing personal health information which that Federal agency maintains in its IRF-PAI System of Records: Call 1-800-MEDICARE, toll free, for assistance in contacting the IRF-PAI System of Records Manager. TTY for the hearing and speech impaired: 1-800-820-1202
Paradigm Home Health provides Home Health, Hospice and Palliative Care services to Central Indiana.
8904 Bash Street, Suite B
Indianapolis, IN 46256
Email: office@plchealth.com
Phone: 317-735-6001
Fax: 855-450-1177
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