WHY WE ASK QUESTIONS Privacy Act Notification Statement of the Indian

to; State, local or other authorized groups to provide health service to you or to reimburse contractors for the services provided to you; Federally approved organizations that evaluate the health care you receive; Persons performing health related research where I.H.S.<br><br> is assured the research will help Native American people and the information will be adequately protected; State or local governmental agencies which by law require the information for the purposes of law enforcement, birth and death reporting and communicable disease control; Local schools for the purpose of providing health care to the children they teach; Organizations (Medicare/Medicaid, insurance companies) for them to reimburse I.H.S. and contract health service provider for services provided to you; Agencies acting on behalf of I.H.S. to collect reimbursable payments or to make payments on behalf of the Indian Health Service.<br><br> Eligibility: Other information is required if we are to determine: Your eligibility to receive health care from the Indian Health Service or contract health service providers (evidence of Indian descent and your residence); Your eligibility to have other agencies such as Medicare, Medicaid, or private insurance companies pay I.H.S. or contractors for part or all of your health care expenses; Your eligibility to receive health care from other organizations (such as the Veterans Administration). These requirements are contained in 42 CFR Section 36.12 and 42 CFR Section 36.23.<br><br> These regulations say that I.H.S. is to obtain information on possible use of other health resources which may be used to provide you with health care. This information is to be obtained before health care is provided to you directly by I.H.S.<br><br> or by contract health providers. Authority : Records of health care provided to you are maintained by I.H.S. under the following laws: Public Health Service Act, Section 321; Indian Self-Determination and Education Assistance Act; Snyder Act; Indian Health Care Improvement Act; Construction of Community Hospitals Act; Indian Health Service Transfer Act.<br><br> I.H.S. employees are required to keep a list of people whom they release information from your medical record. You have a right to see that list.<br><br> The list must show what was released, to whom (name and address), for what purpose and the date of release. You may speak with a person at the outpatient or admitting desk to find out how to do this. The information you provide will be maintained in Health and Medical Records, Systems HHS/PHS/IHS, (System Number 09-17-0019).<br><br> Thank You for Your Help! PRIVACY ACT NOTIFICATION STATEMENT (To be given to persons provided health care by the Indian Health Service (I.H.S.) or by contractors receiving funds from the I.H.S.) When Federal Employees or Federal Contractors keep records about people, they must give the people information about the records they are keeping. The Privacy Act of 1974 (Public Law 93.579) requires that the following be done: 1.<br><br> You have the right to know what records about you are collected, stored, used or given out by the Federal agency or contractor and why. The page titled: cWhy We Ask Questions d which comes before this notice, describes this. More information about the health and medical information I.H.S.<br><br> employees or I.H.S. contract employees keep about you is found in the I.H.S. Health and Medical Records System Notice, 09-17-0019.<br><br> You can get a copy of this notice by asking someone in the I.H.S. or I.H.S. contractor 9s Medical Records Office for it.<br><br> 2. You have the right to authorize I.H.S. employees or I.H.S.<br><br> contract employees to send out information contained in a record about you for a purpose other than the original purpose(s) for which it was collected. Should you wish to do this you will be asked to complete and/or sign a form titled; cAuthorization For Release of Information, d Form No. IHS-810.<br><br> In order to give out a copy of your record (or information contained in your record) for a purpose not covered by the cWhy We Ask Questions d notice or the Systems Notice 09-17-0019, you must give your permission in writing. If you believe that your record is being used improperly, contact someone in the medical records department of the I.H.S. facility or the I.H.S.<br><br> contractor 9s facility where your record is stored and inform them of your objection. You should receive a written reply to your comment within two weeks. If for some reason you do not receive a response within two weeks contact the Service Unit Director for a response to your inquiry.<br><br> 3. You have the right to see the original record or a copy of it, to have a copy made for all or any part of it and to ask for correction of information you believe is incorrect. Copies are made at the expense of the I.H.S.<br><br> Someone in the medical records department where your records is kept will assist you with these procedures. A medically trained individual will first have to examine your record to see if it is in order before this is done. This process generally takes two weeks.<br><br> 4. If you have questions about what is written in your record, you may ask the doctor to explain the entry to you. If you do not agree with an entry in the medical record you may write to the Service Unit Director, state what you disagree with and why and give proper identification (name, address, date of birth and signature).<br><br> This statement will be made a permanent part of your record. You should receive a reply to your inquiry within two weeks. 5.<br><br> I.H.S. employees or I.H.S. contract employees are to ensure that the information stored in each record is (1) collected for necessary and lawful purpose, (2) current and correct, and (3) safeguarded against misuse.<br><br> This is very important to I.H.S. staff. Notify someone in the I.H.S.<br><br> or contractor 9s medical records office if you think one of the above requirements is not being done. You should receive a written reply within two weeks. If for some reason you do not receive a response within two weeks contact the Service Unit Director for a response to your inquiry.<br><br> 6. There are penalties for willful or intentional action which violates your rights under the Privacy Act. Pursuant to the section of the Privacy Act titled, cCivil Remedies, d the Federal agency can be required to pay monetary damages if among other things: A.<br><br> The I.H.S. or I.H.S. contractor does not review your request to make a change to your record or does not make the change if it is justified.<br><br> B. The I.H.S. or I.H.S.<br><br> contractor does not keep your record accurate, current, or complete, which results in inappropriate health care provided to you. Pursuant to the section of the Privacy Act titled, cCriminal Penalties, d a Federal employee or contractor can be required to pay up to $5,000 if: A. An I.H.S.<br><br> employee or an I.H.S. contract employee, who knows that certain types of releases of information about you are prohibited, willfully discloses the information to a person not entitled to receive it. B.<br><br> An I.H.S. employee or an I.H.S. contract employee keeps information about individual people and does not make public notice or it as required by the Privacy Act of 1974.<br><br> C. A person asks for and gets a copy of an individual 9s record under false pretenses. An authorized I.H.S.<br><br> representative will ask you to sign a form which indicates that you have been provided with this notice. The form will be placed in your medial record. It is essential that your signature be in your medical record for comparison in case we receive a written request to release information contained in your record based on your signed consent.<br><br> Thank you for your time and effort in answering the questions we will ask you. The answers you give us will help us to help you better. IHS-819 (10/ 88) U.S.<br><br> Government Printing Office: 1992 - 324 -266 Dk: 2/819

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