NOTICE OF PRIVACY PRACTICES
If you do not speak and/or read English, please call (202) 671-4222 between 8:15 a.m. and 4:45 p.m. A representative will assist you.
Si usted no habla y/o lee Inglés, por favor llame al (202) 671-4222 entre 8:15 a.m. y 4:45 p.m. Un representante le asistirá. -SPANISH
Si vous ne parlez pas et /ou lire en anglais, s'il vous plaît appelez (202) 671-4222 08:15 a.m. - 4:45 p.m. Un représentant vous aidera. -FRENCH
如果您不會說或看不懂英文，請在早上八點到下午六點之間，來電協助熱線 (202) 671-4222，服務代表會協助您。 -CHINESE
ይህንን፡ ደብዳቤ ፡ማንበብ፡ ካልቻሉ፡ የደንበኛ ኣገልግሎቶች፡ መስጫ፡ ጋር፡ በ (202) 671-4222 ስልክ፡ ቁጥር፡ ከ 8፡15 አስከ 4፡45 ይደዉሉ፡ የቢሮ፡ ባልደረባ ፡ የረዳችዋል፡፡ -AMHARIC
Nếu bạn khôn nói/đọc được tiếng Anh, xin gọi Đường Dây Trợ Giúp tại số (202) 671-4222từ 8 giớ sáng đến 6 giớ tối, sẽ có một đạI diện giúp cho bạn. -VIETNAMESE
만약 귀하께서 이 편지를 읽지 못하면, 회원 서비스 부서로 (전화 번호: (202) 671-4222 연락하십시오. (한국어) - KOREAN
If you have a hard time understanding this document, please call us at (202) 671-4222
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
The Department of Health or DC HEALTH keeps your medical information, also known as your protected health information (PHI), confidential.
Your PHI includes your name, address, birth date, and phone number. It also includes your social security number, Medicaid or Medicare number (if any), and health insurance policy information. It may include information about your health condition.
The billing claims by health care providers include your diagnoses. The claims list your medical treatment and supplies. Claims also include physician’s statements, x-rays, and lab test results. Your PHI is this information too.
The law requires us to keep your PHI private. We must provide you with this Notice of our legal duties and privacy practices. The law requires DC HEALTH to abide by this Notice.
USE OF YOUR PHI:
We use your PHI for treatment, payment, and other permitted purposes. We may also use and/or disclose your PHI without your permission when permitted by law:
Treatment: To a health care provider to treat you. (EXAMPLE: DC HEALTH may share your PHI with a clinical laboratory in order to verify your insurance coverage.)
Previous Provider: To your current or past health care provider.
Public Health Activities: For the following kinds of public health activities:
- To run our program
- For research
- To coroners, medical examiners, funeral directors, and organ procurement organizations
- As authorized by DC workers’ compensation laws
- As authorized by the DC Mental Health Act.
- To respond to lawsuits and legal actions
To Avoid Harm or Other Law Enforcement Activities: We may disclose your PHI:
- To stop a serious threat to health or safety
- In response to court/administrative orders
- In response to a medical emergency
- To law enforcement officials
- To correctional institutions
Communication: To contact you personally to keep you informed. (EXAMPLE: DC HEALTH may send appointment reminders or information about other treatment opportunities to you.)
AUTHORIZATION FOR OTHER USES AND DISCLOSURES OF PHI NOT MENTIONED IN THIS NOTICE:
DC HEALTH will only use or disclose your PHI for purposes this Notice mentions. DC HEALTH will never sell your PHI. DC HEALTH will obtain your written authorization for other uses and disclosures. You may revoke your authorization in writing any time.
You may contact the DC HEALTH Privacy Officer at the address listed at the end of this Notice for further information.
YOUR RIGHTS REGARDING YOUR PHI:
You have the following rights with respect to your PHI. In writing, you may:
- Ask us to limit how your PHI is used or given out. We are not required to agree to your request. If we do agree, we will honor it.
- Ask DC HEALTH to talk to you about your rights.
- Generally, see and copy your PHI. You may ask that any refusal to do so be reviewed. You may be charged a reasonable fee for copies.
- Ask DC HEALTH to change your PHI. We may not make your requested changes. If so, we will tell you why we cannot change your PHI. You may respond in writing to any denial. You may ask that both our denial and your response be added to your PHI.
- Get a listing of certain entities that received your PHI from DC HEALTH. This list will not include a listing of disclosures made for treatment or payment. Nor will it include disclosures for healthcare operations, information you authorized us to provide, and government functions.
- Request a paper copy of this Notice of Privacy Practices.
- Be notified of a breach of unsecured PHI, if your PHI is affected
Consent for Covid-19 Diagnostic Testing
I voluntarily consent and authorize the District of Columbia Department of Health (“DC HEALTH”) and its agents to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of a sample by DC HEALTH through a nasopharyngeal swab, oral swab, or other approved collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility for any actions required by me with regard to my test results. If I have any questions regarding this testing or my test results, I will immediately seek advice and treatment from an appropriate health care provider.
I authorize DC Health to file for insurance benefits to pay for the care I receive, including sharing my medical record with my insurance company. I understand that I am not obligated to pay the cost of this test if my insurance does not pay or I do not have insurance.
CONCERNS OR COMPLAINTS ABOUT THE USE OR DISCLOSURE OF YOUR PHI:
For more information about our privacy practices, you may contact the Agency Privacy Officer or the District Privacy & Security Official at either of the following addresses.
DC HEALTH Privacy Officer DC Department of Health
899 N. Capitol Street, NE, 6th Floor
Washington, DC 20002
Voice: (202) 442-5977
Email: [email protected]
District of Columbia Privacy & Security Official DC Office of Health Care Privacy and Confidentiality
400 6th Street, NW
Washington, DC 20001
Voice: (202) 442-9373
Fax: (202) 347-8922
Email: [email protected]
You may also contact the Privacy Officer for additional copies of this Notice. You have the right to complain to us. Complaints will not cause you any harm. To complain to us, please contact DC HEALTH, or the DC Privacy & Security Official. You may also complain to the U.S. Department of Health and Human Services (DHHS). You may send a written complaint to DHHS at the following address:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F HHH Bldg.
Washington, DC 20201
If you have access to a computer, you may submit a complaint form electronically using the OCR Complaint Portal at:
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Alternatively, you may e-mail your own complaint to:
Please check https://www.hhs.gov/civil-rights/filing-a-complaint/index.html for more information on making a complaint to DHHS.
CHANGES TO THIS NOTICE:
We reserve the right to change the terms of this Notice. If we change the terms of this Notice, we will post a revised notice in the DC HEALTH privacy office. In addition, the current Notice of Privacy Practices will be posted on the Internet at dchealth.dc.gov.