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Privacy Act Statement-Health Care Records (Medicare form)
Home Health Agency Outcome and Assessment Information Set (OASIS): Statement of Patient Privacy Rights (Medicare form)
Home Health Agency Outcome and Assessment Information Set (OASIS): Notice About Privacy (Medicare form)



Home Nursing Services (“Agency”) may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for the care and conducting health care operations.  The Agency has established policies to guard against unnecessary disclosure of your health information.


To Provide Treatment.  The Agency may use your health information to coordinate care within the Agency and with others involved in your care, such as your attending physician, members of the Agency interdisciplinary team and other health care professionals who have agreed to assist the Agency in coordinating care.  For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.  The Agency also may disclose your health care information to individuals outside of the Agency involved in your care including family members, clergy who you have designated, pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment.  The Agency may include your health information in invoices to collect payment from third parties for the care you receive from the Agency.  For example, the Agency may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Agency.  The Agency also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for Agency care and the services that will be provided to you.

To Conduct Health Care Operations. The Agency may use and disclose health information for its own operations in order to facilitate the function of the Agency and as necessary to provide quality care to all of the Agency’s clients.  Health care operations includes such activities as:

  • Quality assessment and improvement activities.
  • Activities designed to improve health or reduce health care costs.          
  • Protocol development, case management and care coordination.
  • Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
  • Professional review and performance evaluation. Training programs including those in which students, trainees or practitioners in health care learn under supervision.
  • Training of non-health care professionals.
  • Accreditation, certification licensing or credentialing activities.
  • Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
  • Business planning and development including cost management and planning related analyses and formulary development.
  • Business management and general administrative activities of the Agency.

For example, the Agency may use your health information to evaluate its staff performance, combine your health information with other Agency clients in evaluating how to more effectively serve all Agency clients, disclose your health information to Agency staff and contracted personnel for training purposes, or use your health information to contact you as a reminder regarding a visit to you, (unless you tell us you do not want to be contacted.)

For Appointment Reminders.  The Agency may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit.

For Treatment Alternatives.  The Agency may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. 


When Legally Required.  The Agency will disclose your health information when it is required to do so by any Federal, State or local law. 

When There are Risks to Public Health.  The Agency may disclose your health information for public activities and purposes in order to:

  • Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
  • Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
  • Notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence.  The Agency is allowed to notify government authorities if the Agency believes a client is the victim of abuse, neglect or domestic violence.  The Agency will make this disclosure only when specifically required or authorized by law or when the client agrees to the disclosure.

The Conduct Health Oversight Activities.  The Agency may disclose your health information to a health oversight Agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action.  The Agency, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.         

In Connection with Judicial and Administrative Proceedings.  The Agency may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes.  As permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similarprocess.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • To a law enforcement official if the Agency has a suspicion that your death was the result of criminal conduct including criminal conduct at the Agency.
  • In an emergency in order to report a crime.

To Coroners And Medical Examiners.  The Agency may disclose your health information to coroners and medical examiners for purposes of determining your case of death or for other duties, as authorized by law.

To Funeral Directors.  The Agency may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements.  If necessary to carry out their duties, the Agency may disclose your health information prior to and in reasonable anticipation of your death.

For Organ, Eye Or Tissue Donation.  The Agency may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes.  The Agency may, under very select circumstances, use your health information for research.  Before the Agency discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.

In the Event of A Serious Threat To Health Or Safety.  The Agency may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Agency, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions.  In certain circumstances, the Federal regulations authorize the Agency to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation.  The Agency may release your health information for worker’s compensation or similar programs.


Other than is stated above, the Agency will not disclose your health information other than with your written authorization.  If you or your representative authorizes the Agency to use or disclose your health information, you may revoke that authorization in writing at any time.


You have the following rights regarding your health information that the Agency maintains:

  • Right to request restrictions.  You may request restrictions on certain usesand disclosures of your health information.  You have the right to request a limit on the Agency’s disclosure of your health information to someone who is involved in your care or the payment of your care.  However, the Agency is not required to agree to your request.  If you wish to make a request for restrictions, please contact the Administrator.
  • Right to receive confidential communicatons.  You have the right to request that the Agency communicate with you in a certain way.  For example, you may ask that the Agency only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Agency
    Administrator.  The Agency will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
  • Right to inspect and copy your health information.  You or your representative has the right to request that the Agency amend your records, if you believe that your health information is incorrect or incomplete.  That request may be made as long as the information is maintained by the Agency.  A request for an amendment of records must be made in writing to the Administrator.  The Agency may deny the request if it is not in writing or does not include a reason for the amendment.  The request also may be denied if your health information records were not created by the Agency, if the records you are requesting are not part of the Agency’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of the Agency, the records containing your health information are accurate and complete.
  • Right to an accounting.  You or your representative has the right to request an accounting of disclosures of your health information made by the Agency for certain reasons, including reasons related to public purposes authorized by law and certain research.  The request for an accounting must be made in writing to the Administrator.  The request should specify the time period for the accounting starting on or after April 14, 2003.  Accounting requests may not be made for periods of time in excess of seven (7) years.  The Agency would provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.
  • Right to a paper copy of this notice.  You or your representative has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously.  To obtain a separate paper copy, please contact:

528 West Washington Blvd.
Fort Wayne, Indiana, 46802
(260) 424-1237
Toll free: (888) 424-1237


The Agency is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices.  The Agency is required to abide by the terms of this Notice as may be amended from time to time.  The Agency reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains.  If the Agency changes its Notice, the Agency will provide a copy of the revised Notice to you or your appointed representative.  You or your personal representative has the right to express complaints to the Agency and to the Secretary of DHHS if you or your representatives believe that your privacy rights have been violated.  Any complaints to the Agency should be made in writing to the Administrator, 528 West Washington Blvd., Fort Wayne, Indiana 46802.  The Agency encourages you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint.


The Agency has designated the Administrator as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. 
528 West Washington Blvd.
Fort Wayne, Indiana, 46802
(260) 424-1237
Toll free: (888) 424-1237


This Notice is effective April 14, 2003.

528 West Washington Blvd.
Fort Wayne, Indiana, 46802
(260) 424-1237
Toll free: (888) 424-1237

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