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PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
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 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(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 collect 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 Privacy Act of 1974 (5 U.S.C. 552a), as amended. You have the right to see, copy, review, and request correction
of your information. Instructions on how to access information collected about you is included in the HHA OASIS system of records
notice, located at https://www.hhs.gov/foia/privacy/sorns/09700522/index.html.
II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED
The information collected will be entered into the HHA OASIS System No. 09-70-9002. Your health care information will be used for
the following purposes. To:
study and help ensure the quality of care provided by home health agencies (HHA)
aid in administration of the survey and certification of Medicare/Medicaid HHAs
enable regulators to provide HHAs with data for their internal quality improvement activities
support agencies of the state government to determine, evaluate and assess overall effectiveness and quality of HHA
services provided in that state
provide for the validation, and refinements of the Medicare Prospective Payment System
aid in the administration of Federal and state HHA programs within the state; and
monitor the continuity of care for patients who reside temporarily outside of the state.
III. ROUTINE USES
These routine uses specify the circumstances when the Centers for Medicare & Medicaid Services may disclose your information from
HHA OASIS without your consent, in accordance with 5 U.S.C.552a(b)(3). Each prospective recipient of a routine use disclosure must
agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of the information may be to:
support agency contractors, consultants, or grantees, to assist in the performance of a service related to this collection and
who need to have access to the records.
assist another Federal or state agency in contributing to the accuracy of CMS's proper payment of Medicare benefits, enable
such agency to administer a Federal health benefits program, fulfill a requirement of a Federal statute or regulation and/or
evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance operations.
assist an individual or organization for research, evaluation or epidemiological projects related to the prevention of disease
or disability, or the restoration or maintenance of health, and for payment related projects.
support Quality Improvement Organizations (QIO) in order to assist the QIO to perform Title XI and Title XVIII functions
relating to assessing and improving HHA quality of care.
support national accrediting organizations with approval for deeming authority for Medicare requirements for home health services.
support the Department of Justice (DOJ), court or adjudicatory body when the agency is a party to litigation
assist a CMS contractor that assists in the administration of a CMS-administered health benefits program, or to a grantee of
a CMS-administered grant program, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover,
detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud,
waste, or abuse in such program.
assist another Federal agency or to an instrumentality of any governmental jurisdiction that administers, or that has the authority
to investigate potential fraud, waste, or abuse in, a health benefits program funded in whole or in part by Federal funds.
IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION
The home health agency needs the information contained 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
also could 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 services.
NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies
may request you or your representative to sign this statement to document 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.
CONTACT INFORMATION
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 of 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.
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