Your Best Pathway to Health
Volunteer Waiver and Disclosure Form
Compliance:
I hereby attest that all information submitted on this application form and supporting documents (license/certificate) are currently in force and not restricted, suspended or revoked. I further attest that I will comply with Your Best Pathway to Health protocols, bylaws and manual. I agree to the mission of Your Best Pathway to Health and I am committed to patient care through Christ’s methods.
HIPAA has 3 Main Objectives:
HIPAA stands for Health Insurance Portability and Accountability Act of 1996, also referred to as Kennedy-Kassebaum Act. This statute called for the Department of Health and Human Services (DHHS) to adopt standards for electronic data interchange (EDI) and codes sets, uniform health care identifiers, and standards for the protection of privacy and security of patient data.
HIPAA has 3 main objectives:
1. Insurance portability
2. Fraud enforcement (accountability)
3. Administrative simplification (reduction of healthcare costs)
Essentially, anyone who receives health care can apply their patient rights under HIPAA. Applying these patient rights will help control how an institution can use or share information called ProtectedHealthInformation or PHI.
PHI is any health information that:
• directly or indirectly identifies a patient
• pertains to the past, present and future condition of the patient
• is transmitted verbally, in writing, or electronically
Examples of PHI is:
The Privacy Patient Rights:
Right to Access – patients have the right to access, inspect and obtain a copy of PHI contained in their medical or billing record.
Right to Amend – patients have the right to request an amendment or change to the PHI contained in their medical or billing record.
Right to Disclosures – patients have a right to request a list of when and to whom their confidential information was released (called an accounting of disclosures).
Right to Request Restrictions – patients have the right to:
A. Request restrictions on how we use or share their PHI with others for treatment payment and health care operations.
B. Request restrictions on how much information should be shared with others in the facility directory of patient locator.
C. Request a restriction on the information shared with family or friends involved in the patient’s care.
We are not required to agree to a restriction, so DO NOT agree to arestriction!
Right to Request Alternative Communication – patients have the right to request that we send communications of PHI through an alternative means or to alternative locations. The Privacy Rule requires that we accommodate requests that are reasonable.
Right to File a Complaint – if the patient feels that his or her privacy rights were violated, he or she has the right to file a complaint with the organization and the Secretary of the Department of Health and Human Services.
Right to Receive Notice – the patient has the right to receive a notice of the privacy practices of the organization. The notice must include how the organization uses and discloses the information, how to obtain records, and how to file a complaint.
This means that one should request only the (least amount) specific information needed to complete the task.
Minimum Necessary:
This means that one should request only the (least amount) specific information needed to complete the task.
Organized Health Care Arrangement (OHCA) is more than one entity that participates together in the sharing of PHI, uniform method of HIPAA compliance and monitoring processes, and uniform agreement of restrictions.
When PHI is requested, determine if it is being shared within the OHCA for:
• Treatment purposes
• Payment purposes
• Health Care Operations
If “Yes” to any of the above, then patient authorization is NOT needed.
If “No” to any of the above, then patient authorization IS required. You must forward the request for PHI to the Registration, Exit Management, or Medical Records Department.
* Health Care Operations, or Treatment/Payment/Operations (TPO),includes:
? quality assessment and improvementactivities
? population-based activities related to improvementactivities
? protocoldevelopment
(researchdoneforQualityImprovementpurposesistheonlyresearchconsideredTPO)
? case management and carecoordination
? contactinghealthcareprovidersandpatientswithinformationabouttreatmentalternatives
? review of competence/qualifications of health careprofessionals
? practitioner and provider performanceevaluation
? conducting trainingprograms
? other activities relating to health benefitcontracts
? medical review, internal legal and auditingfunctions
? business planning anddevelopment
? administrativeactivities
? activities relating to the sale, transfer, merger or consolidation of thecovered entity
? fundraising for the benefit of the covered entity (conditionsapply)
Breaches in Privacy:
Both individuals and organizations can be held liable for breaches in privacy. Intentionally releasing information would be punishable by a fine of up to $50,000 and one year in jail. Someone trying to sell information could face a $250,000 fine and 10 years in prison. Civil penalties of up to $100 for each unintentional violation, and up to a $25,000 limit per identical violation could apply.
Confidentiality:
I understand that while I am participating as a registered volunteer at YbPTH event, it is mandatory that I maintain the privacy and confidentiality of all patients. This pertains to all present and future digital, written and verbal communications referring to any YbPTH patient. I also understand that unless I am obtaining information strictly for patient registration, I will not ask a patient any questions regarding medical insurance coverage, Medi-Cal or Medicare. I further agree not to photograph or record patients unless authorized to do so while at the YbPTH event. I acknowledge that I have read, understand and agree to adhere to this policy of confidentiality for YbPTH.
Release:
I hereby release Your Best Pathway to Health, a 501 (c ) (3) non-profit entity, and all of its respective officers, directors, employees agents, volunteers, contractors, heirs, successors and assigns (hereinafter the “Released Parties”) from prosecution or presentation of any claim for bodily injury, damages, wrongful death or property loss or damage incurred in connection with my attendance and/or performance of health care services including ancillary services or related activities at the YbPTH events.
