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Big Bear Lake Urgent Care is a Management Services Organization
Big Bear Lake Urgent Care is a Management Services Organization
PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
INFORMATION PERTAINING TO YOU:
1. AUTHORITY
FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN)
Sections 1819(f),
1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.
2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED
This form provides
you the advice required by The Privacy Act of 1974. The personal information will
facilitate tracking of changes in your health and functional status over time for
purposes of evaluating and assuring the quality of care provided by nursing homes
that participate in Medicare or Medicaid.
3. ROUTINE USES
The primary use of this information
is to aid in the administration of the survey and certification of Medicare/Medicaid
long-term care facilities and to improve the effectiveness and quality of care given
in those facilities. This system will also support regulatory, reimbursement, policy,
and research functions. This system will collect the minimum amount of personal data
needed to accomplish its Stated purpose.
The information collected will be entered
into the Long-Term Care Minimum Data Set (LTC MDS) system of records, System No.
09-70-1517. Information from this system may be disclosed, under specific circumstances
(routine uses), which include: To the Census Bureau and to: (1) Agency contractors,
or consultants who have been engaged by the Agency to assist in accomplishment of
a CMS function, (2) another Federal or State agency, agency of a State government,
an agency established by State law, or its fiscal agent to administer a Federal health
program or a Federal/State Medicaid program and to contribute to the accuracy of
reimbursement made for such programs, (3) to Quality Improvement Organizations (QIOs)
to perform Title XI or Title XVIII functions, (4) to insurance companies, underwriters,
third party administrators(TPA),employers, self-insurers, group health plans, health
maintenance organizations (HMO) and other groups providing protection against medical
expenses to verify eligibility for coverage or to coordinate benefits with the Medicare
program, (5) an individual or organization for a research, evaluation, or epidemiological
project related to the prevention of disease of disability, or the restoration of
health, or payment related projects, (6) to a member of Congress or congressional
staff member in response to an inquiry from a constituent, (7) to the Department
of Justice, (8) to 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, (9)
to another Federal agency or to an instrumentality of any governmental jurisdiction
that administers, or that has the authority to investigate potential fraud or abuse
in a health benefits program funded in whole or in part by Federal funds to prevent,
deter, and detect fraud and abuse in those programs, (10) to national accrediting
organizations, but only for those facilities that these accredit and that participate
in the Medicare program.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT
ON INDIVIDUAL OF NOT PROVIDING INFORMATION
For Nursing Home residents residing in
a certified Medicare/Medicaid nursing facility the requested information is mandatory
because of the need to assess the effectiveness and quality of care given in certified
facilities and to assess the appropriateness of provided services. If the requested
information is not furnished the determination of beneficiary services and resultant
reimbursement may not be possible.
Your signature on the form provided at the office
merely acknowledges that you have been advised of the foregoing. If requested, a
copy of this form will be furnished to you.
