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D%/$0,#%,(&;!!OE,!&'*%*)8!$D!A,$A%,!)$!A&()*#*A&),!D6%%8!*+!)E,!2,#*/*$+/!&+2!A($#,//,/!)E&)!/E&A,!)E,*(! %*4,/;K,",+,-"P'/1700,>,57+,-"P'7":'E&0+)90'->'E$??-%+0!bKK)E!M2*)*$+c!P$(%2!.,&%)E!W(I&+*X&)*$+$#V-2$/;!"!D&#*%*)8!$(!A($I(&@!)E&)!A($4*2,/!4$#&)*$+&%!,NA,(*,+#,!*+!&!#$+)($%%,2!-$(H*+I! ,+4*($+@,+)!)$!A,$A%,!-*)E!2*/&'*%*)*,/S! ! or the identity, description or location of the person who committed the crime. .. If you are under the custody of law enforcement, we may give out health information about you to the law enforcement officials or agency to provide you the necessary health care, to protect your health and safety or the health and safety of others or the safety and security of the agency. Coroners, Medical Examiners and Funeral Directors: We may give out health information to a corner or medical examiner. This may be necessary, for example to identify the person who died or find the cause of death. We may also give out health information about residents/consumers of the agency to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities: We may give out health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations for their protection. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU: You have the following rights regarding health information we collect about you: Right to Inspect and Copy: You have the right to look at and receive a copy of health information that may be used to make decisions about your services. Usually, this includes medical and billing records, but does not include psychotherapy notes. To look at and/or receive a copy of health information that may be used to make decisions about you, contact the person managing your services. If you ask for a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies in order to give you your copies. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may ask that the denial be reviewed. The Executive Director will review the denial. We will accept the outcome of the review. Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to correct the information. You have the right to request a correction as long as the information is kept by or for Hills & Dales. .. To ask for a correction, you must do so in writing and give it to the Contact Person with Hills & Dales. In addition, you must have a reason that supports your request. .. We may deny your request for correction if it is not in writing or does not include a valid reason to support the request. In addition, we may deny your request if you ask us to change information that: ! Was not created by us or the person or entity that created the information is no longer available to make the correction; ! Is not part of the health information kept by or for Hills & Dales; ! Is not part of the information which you would be allowed to inspect and copy, or ! Is already accurate and complete. Right to an Accounting of Disclosures: ........ .......... ........ ............ ...... ................ ...... ........................ ...... .............................................................................................................. health information about you to others except for purposes of treatment, payment and operations identified about. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2004. Your request should tell us in what form you want the list (for example, on paper or electronically). You may ask for one free list in a 12-month time period. For additional lists, we may charge you for the costs of providing the list. We will tell you the cost and you >K! ! may choose to change your request at that time before any costs are added. Right to Request Restrictions: You have the right to ask for a limitation on the health information we use or give out about you for treatment, payment or health care operations. You also have the right to ask for a limit on the health information we give out about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request a limitation, you must request the limitation in writing to the Contact Person with Hills & Dales at 1011 Davis Street, Dubuque, Iowa 52001. In your request, you must tell us what information you wanted to limit, whether you want to limit the use or giving out of health information or both or to whom you want the limits to apply. We are not required to agree to your request. If we do agree, we will honor your request unless the information is needed to provide you with emergency treatment. Right to Request Confidential Communication: You have the right to ask that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, home or by mail. To ask for confidential communications, you must make your request in writing to the Contact Person with Hills & Dales. We will not ask you the reason for your request. We will accept all reasonable requests. Your request must tell us how or where you wish to be contacted. Right to a Paper Copy of this Notice: You may have the right to receive a paper copy of this privacy notice. You may ask us to give you a copy of this privacy notice at any time by reaching the Contact Person with Hills & Dales at (563)556- 7878. CHANGES TO THIS NOTICE: We have the right to change this notice. We have the right to make the changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at the 1011 Davis Street and the Stoneman Road sites of Dubuque, Iowa. COMPLAINTS: If you believe your privacy rights have been violated, you may contact or submit your complaint in writing to the Contact Person(s) (Director of Residential Operations or Director of Community Operations) with Hills & Dales, 1011 Davis Street, Dubuque, Iowa 52001; (563)556-7878. The Privacy Officer will be notified of any complaints and the resolution. The Privacy Officer may be involved in the complaint resolution. If we cannot settle your concern, you also have the right to file a written complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. The quality of your care will not depend on nor will you be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION: Other uses and giving out health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or give out health information about you, you may take back that permission; after which, we will no longer use or give out health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any information we have already given out with your permission, and that we are required to keep our records of the care that we provided to you. Revised 1/20/05, 10/07, 9/09 tkp >;! ! ! >>! ! ?//,(.'7!S;!H'5,#5',0!................N#$4/!:$(6'.,(&'*1'&C!?)#,,%,(&..! 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