THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974) THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED OR TO USE YOUR HEALTH CARE INFORMATION.
AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER, AND WHETHER OR NOT YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THE ASSESSMENT SECTIONS 1102(A), 1154, 1861(O), 1861(Z), 1863, 1864, 1865, 1866, 1871, 1891(B) OF THE SOCIAL SECURITY ACT
Medicare and Medicaid participating home health agencies must do a complete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the “Outcome and Assessment Information Set” (OASIS) when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Centers for Medicare & Medicaid Services (CMS, the federal Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate health care to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the federal Privacy Act of 1974, and the “Home Health Agency Outcome and Assessment Information Set” (HHA OASIS) System of Records. You have the right to see, copy, review, and request correction of your information in the HHA OASIS System or Records.
PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED
These “routine uses” specify the circumstances when the Centers of Medicare & Medicaid Services may release your information from the HHA OASIS 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 the information may be to:
I. The Federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services;
II. Contractors or consultants working for the Centers for Medicare & Medicaid Services to assist in the performance of a service related to this System of Records and who need to access these records to perform the activity;
III. An agency of a State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or, quality of health care services provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of Federal/State home health agency programs within the State;
IV. An agency of a State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services’ health insurance operations (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs;
V. Quality Improvement Organizations, to perform Title XI or title XVII functions relating to assessing and improving home health agency quality of care;
VI. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment related projects;
VII. A congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained.
EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION
The home health agency needs the information in the Outcome and Assessment Information Set in order to give you quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information could also make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you service
NOTE; This statement may be included in the admission packet for all new health agency admissions. Home health agencies may request you or your representative to sign this statement to documents that this statement was given to you. Your signature is NOT required. If you or your representative sign the statement the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement.
If you want to ask the Centers for Medicare & Medicaid Services to see, review, copy, or correct your personal health information that the Federal agency maintains in its HHA OASIS System Records;
Call 1-800-MEDICARE, toll free for assistance in contacting the HHA OASIS System Manager,
TTY for the hearing and speech impaired: 1-877-486-2048