135 Hoyt Street Athens, GA 30601 (706) 549-4850 Volunteer Opportunities Make a Donation Support Groups Athens Community Council on Aging is a United Way of Northeast Georgia agency.

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. INTRODUCTION During the course of providing services and care to you, the Athens Community Council on Aging, Inc. gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is characterized as your "protected health information." This Notice of Privacy Practices describes how the Athens Community Council on Aging, Inc maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information. THE ATHENS COMMUNITY COUNCIL ON AGING'S RESPONSIBILITIES The Athens Community Council on Aging, Inc. is required by federal and state law to maintain the privacy of your protected health information. The Athens Community Council on Aging, Inc is also required by law to provide you with this Notice of Privacy Practices that describes the Athens Community Council on Aging's legal duties and privacy practices with respect to your protected health information. The Athens Community Council on Aging, Inc will abide by the terms of this Notice of Privacy Practices. The Athens Community Council on Aging, Inc reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that it maintains, including protected health information already in its possession. If the Athens Community Council on Aging, Inc changes its Notice of Privacy Practices, it will personally deliver or mail a revised notice to you at your current address. USE AND DISCLOSURE WITH YOUR AUTHORIZATION The Athens Community Council on Aging, Inc will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. The Athens Community Council on Aging, Inc. has prepared an authorization form for you to use that authorizes The Athens Community Council on Aging, Inc to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. The Athens Community Council on Aging, Inc then will not use or disclose your protected health information, except where it has already relied on your authorization. HOW THE ATHENS COMMUNITY COUNCIL ON AGING, INC. MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION Mandatory Disclosures The Athens Community Council on Aging, Inc will disclose protected health information to outside persons or entities without your written authorization as required by law in the following circumstances: Court Order; Order of Administrative Tribunal The Athens Community Council on Aging, Inc will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency. Subpoena The Athens Community Council on Aging, will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or attempts will be made to obtain an order or agreement protecting your protected health information. Law Enforcement Agencies The Athens Community Council on Aging, Inc will disclose protected health information to law enforcement agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons. Coroner The Athens Community Council on Aging, Inc will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to notify next of kin; or to investigate deaths that may involve public health concerns, suspicious circumstances, elder abuse, or organ or tissue donation. Elder Abuse Reporting The Athens Community Council on Aging, Inc will disclose protected health information about a participant who is suspected to be the victim of elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain circumstances, The Athens Community Council on Aging, Inc may disclose further protected health information about the participant to aid the investigating agency in performing its duties. The Athens Community Council on Aging, Inc will promptly inform the participant about any disclosure unless The Athens Community Council on Aging, Inc believes that informing the participant would place the participant in danger of serious harm, or would be informing the participant's personal representative, whom the Provider believes to be responsible for the abuse, and believes that informing such person would not be in the participant's best interest. Other Disclosures Required by Law The Athens Community Council on Aging, Inc will disclose protected health information about a participant when otherwise required by law. Permissive Disclosures The Athens Community Council on Aging, Inc may, in its discretion, use or disclose your protected health without your written authorization in the following circumstances: Your Care and Treatment The Athens Community Council on Aging, Inc may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For example, the Athens Community Council on Aging, Inc may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. The Athens Community Council on Aging, Inc may also disclose your protected health information to individuals who will be involved in your care if you leave the Athens Community Council on Aging, Inc. Billing and Payment Veteran's Administration, Medicaid and Other Public or Private Health Insurers - The Athens Community Council on Aging, Inc may use or disclose your protected health information to public or private health insurers (including medical insurance carriers, HMOs and Medicare) in order to bill and receive payment for your treatment and services that you receive from The Athens Community Council on Aging, Inc. The information on or accompanying a bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. Health Care Providers - The Athens Community Council on Aging, Inc may also disclose your protected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed. Health Care Operations The Athens Community Council on Aging, Inc may use your protected health information for health care operations at The Athens Community Council on Aging, Inc. These uses and disclosures are necessary to manage the Athens Community Council on Aging, Inc. and to monitor our quality of services and care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff in caring for you. Licensing and Accreditation The Athens Community Council on Aging, Inc may disclose your protected health information to any government or private agency, such as to the Georgia Division of Aging Services, Georgia Office of Regulatory Services, or Northeast Georgia Area Agency on Aging, responsible for licensing or accrediting the Athens Community Council on Aging so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight. Provision of Basic Information about Participants The Athens Community Council on Aging, Inc. allows staff to provide certain basic information about a participant to persons who ask for the participant by name and to members of the clergy. Unless you notify The Athens Community Council on Aging, Inc that you object, it will disclose your name, your location in The Athens Community Council on Aging, Inc, and your general condition to anyone who asks for you by name. It will disclose your name, your location in The Athens Community Council on Aging, Inc, your general condition, and your religious affiliation to members of the clergy. Individuals Involved in Your Care or Payment for Your Care Unless you specifically object, The Athens Community Council on Aging, Inc. may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person's involvement with your care or directly relevant to payment related to your care. The Athens Community Council on Aging, Inc may also disclose your protected health information to a family member, personal representative, or other person responsible for your care to assist in notifying them of your location, general condition, or death. Disaster Relief The Athens Community Council on Aging, Inc may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts. Disclosures within Provider Community Unless you specifically object, The Athens Community Council on Aging, Inc. may disclose certain general information about you (e.g., past activities, present interests, birthday, and location if hospitalized) to members of its community, including other participants and staff, by means such as newsletter or bulletin board. Business Associates The Athens Community Council on Aging, Inc. may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, legal, or accounting services. The Athens Community Council on Aging, Inc. may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on the Athens Community Council on Aging's behalf. The Athens Community Council on Aging, Inc. will have a contract with its business associates that obligate the business associates to maintain the confidentiality of your protected health information. Fundraising The Athens Community Council on Aging, Inc. may use certain protected health information to contact you in an effort to raise money for the Athens Community Council on Aging, Inc. and its operations. The Athens Community Council on Aging, Inc. may disclose the protected health information to business associates or to related foundations that it uses to raise funds for its own benefit. The Athens Community Council on Aging, Inc. will disclose only your name, address, and phone number and the dates you receive health care services. You may notify The Athens Community Council on Aging, Inc. in writing if you object to such disclosures. Research The Athens Community Council on Aging, Inc. may disclose your protected health information for research purposes, provided that the Athens Community Council on Aging's Board of Directors overseeing the research approves the disclosure of the information without a written authorization. Public Health Activities The Athens Community Council on Aging, Inc may disclose protected health information to any public health authority that is authorized by law to collect it for purposes of preventing or controlling disease, injury, or disability. Coroner The Athens Community Council on Aging Inc. may disclose protected health information to the coroner to allow the coroner to perform its duties. Members of Workforce It is the Athens Community Council on Aging's policy to allow members of its workforce to share participants' protected health information with one another to the extent necessary to permit them to perform their legitimate functions on Athens Community Council on Aging's behalf. At the same time, Athens Community Council on Aging, Inc will work with and train its workforce members to ensure that there are no unnecessary or extraneous communications that will violate the rights of its participants to have the confidentiality of their protected health information maintained. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION You have the following rights with respect to your protected health information. To exercise these rights, contact Athens Community Council on Aging, Inc. at the following address: Athens Community Council on Aging, Inc. , 135 Hoyt Street, Athens, Georgia 30601, Attention: Privacy Official. Right to Receive a Copy of the Notice of Privacy Practices You have the right to request and receive a copy of the Athens Community Council on Aging's Notice of Privacy Practices for Protected Health Information in written form. Right to Request Access You have the right to inspect and copy your health records maintained by Athens Community Council on Aging, Inc. In certain limited circumstances, Athens Community Council on Aging, Inc may deny your request as permitted by law. Right to Request Amendment You have the right to request an amendment to your health records maintained by Athens Community Council on Aging, Inc. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an opportunity to submit a written statement disagreeing with the denial. Right to Request Use or Disclosure Restrictions or Confidential Communications You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. Athens Community Council on Aging, Inc. is not required to grant your request, but if it does, it will comply with your request, except in an emergency situation or until the restriction is terminated by you or Athens Community Council on Aging, Inc. You also have the right to request that Athens Community Council on Aging, Inc. communicate protected health information to the recipient by alternative means or at alternative locations. COMPLAINTS If you believe that your privacy rights have been violated, you may file a complaint with Athens Community Council on Aging, Inc. at the following address 135 Hoyt Street Athens, Georgia 30601, Attention: Contact Person. You also have the right to submit a complaint to the Secretary of the U.S. Department of Health and Human Services, Sam Nunn Atlanta Federal Center 61 Forsyth Street SW, Atlanta, GA 30303-8909, Attention OCR Regional Manager. Athens Community Council on Aging, Inc. will not retaliate against you if you file a compliant. FURTHER INFORMATION If you have questions about this Notice of Privacy Practices or would like further information about your privacy rights, contact Athens Community Council on Aging, Inc. at the following address 135 Hoyt Street Athens, Georgia 30601, Attention: Privacy Official. The effective date of this Notice of Privacy Practices is October 15, 2003.