THIS NOTICE TELLS YOU HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Community Care is committed to keeping your health information private.

The law requires Community Care to make sure that we keep your health information private, that we provide you this notice of our privacy practices, and that we follow the terms of this notice that are currently in effect.

This information is also available in Spanish. If you need this Notice of Privacy Practices in Spanish or another language please call (414) 385-6600 (Toll free (866) 992-6600; TTY (414) 385-6626). Community Care also offers interpreter services free of charge.

(Insert Spanish translation of above paragraph here.)

This Notice is for participants and clients of the following Community Care programs:

• Program of All-Inclusive Care for the Elderly (PACE)*
• Wisconsin Partnership Program (Partnership)*
• Comprehensive Community Care Program (CCCP)
• Grandfathered CCO Demonstration Program (GCCO)

*Community Care Health Plan, Inc. administers the PACE and Partnership programs.

COMMUNITY CARE MAY USE OR SHARE YOUR HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE FUNCTIONS.

• For Treatment: We will use and share your health information to provide you with treatment and service and to arrange your care. We may share information with other providers involved in your care. Doctors, nurses, and home health aides involved in your care may use your health information. Specialists, social workers, and others involved in your care may also use your information.

• For Payment: We may use and share your health information for billing and payment. We may share your health information with your personal representative or with an insurance company. We may share your information with the federal and state programs that oversee Community Care’s programs. For example, we may share information to decide if you are eligible for Community Care’s programs. We also require you to sign a release to permit us to share your personal information with federal and state programs. This is part of your enrollment agreement.

• For Health Care Functions: We may use and share your health information as needed for health care functions like management, training, and reviewing quality of care. For example, we may share your health information with another clinic that you have gone to so your nurses and doctors can coordinate your care.

SOME SPECIFIC WAYS THAT COMMUNITY CARE MAY USE OR SHARE YOUR HEALTH INFORMATION...

• People Involved in Your Care or Payment for Your Care: Unless you object, we may share health information about you with a family member, close personal friend or other person you name who is involved in your care. An example is a member of the clergy.

• Emergencies: We may use or share your health information as needed in emergencies.

• Appointment Reminders: We may use or share health information to remind you about appointments.

• Treatment Options and Health-Related Benefits and Services: We may use or share your health information to tell you about treatment options and health-related benefits and services that may be of interest to you.

• Business Associates: Our Business Associates are people and organizations that carry out functions for us that involve protected health information like audits and lab services. We may share your health information with a Business Associate if they need it to perform functions for Community Care. Our Business Associates will also to keep your information private.

• Public Health: We may share your health information for public health functions. These functions may include sending reports to a public health agency to prevent or control disease. We may also report deaths and elder abuse or neglect.

• Reporting Victims of Abuse, Neglect or Domestic Violence: If we feel that you have been a victim of abuse, neglect or domestic violence, we may use and share your health information. We would do this to notify a government agency if allowed by law or if you agree to the report.

• Government Health Care Regulators: We may share your health information with a health care regulatory agency for functions allowed by law. The functions might include audits or reviews related to health care regulations. As a part of your enrollment, we require you to sign a form to allow us to share your information with state and federal programs that oversee Community Care’s programs.

• To Avert a Serious Threat to Health or Safety: When we need to stop a serious threat to your health or safety or the health or safety of the public or another person, we may use or share health information. We limit our sharing to someone who can help lessen or prevent harm.

• Judicial and Administrative Proceedings: We may share your health information in response to a court or administrative order. We also may share information if we get a subpoena, discovery request, or other lawful process. We will try to contact you about the request or to obtain an order or agreement to protect the information.

• Law Enforcement: We may share your health information to enforce the law. For example, we may share information to comply with required reports; to comply with a court order, warrant, or other legal process; or to answer a request for information about a crime.

• Research: We may use or share your health information for research. We will first review and approve the privacy aspects. We may use or share information if it is needed for a research proposal, if the research occurs after your death, or if you permit the use or sharing.

• Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations: We may give your health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

• Disaster Relief: We may share health information about you with a disaster relief organization.

• Military, Veterans and other Specific Government Functions: If you are a member of the armed forces, we may use and share your health information as required by the military. We may share health information for national security purposes. We may also share it as needed to protect the President of the United States or other officials or to conduct special investigations.

• Fundraising: We may use certain information to contact you to raise funds for Community Care and its functions.

• As Required By Law: We may use or share your health information when required by law.

EXCEPT AS DESCRIBED IN THIS NOTICE, WE WILL USE AND SHARE YOUR HEALTH INFORMATION ONLY WITH YOUR WRITTEN PERMISSION (AUTHORIZATION).

• You can revoke your authorization in writing at any time. If you revoke an authorization, we will no longer use or share your health information for the reasons that you had authorized, except where we have already relied on the authorization.

YOUR HEALTH INFORMATION RIGHTS...

Each of these rights is subject to conditions, limits and exceptions. To practice these rights you may have to submit a written request to Community Care. If you ask, Community Care will give you the right form to fill out.

• Request a Paper Copy of This Notice: You have the right to get a paper copy of this Notice, even if you have agreed to get an electronic Notice (e.g., e-mail). You may ask for a copy of this Notice at any time. Also, you can click here to view a printer-friendly copy of this Notice.

• Access your Personal Health Information: You have the right to inspect and get a copy of your clinical or billing records or other written information that we may use to decide about your care. There are some exceptions. Your request must be made in writing. In most cases we may charge a fee for our costs to copy and mail your information.

• Request Changes: You have the right to request changes to your health information kept by Community Care for as long as Community Care has it. Your request must be made in writing and must give the reason for the change. We may deny your request for change if the information...

  (a) Was not made by Community Care, unless the maker of the information no longer exists to act on your request;

  (b) Is not part of the health information kept by or for Community Care;

  (c) Is not part of the information to which you have a right of access; or

  (d) Is already correct and whole, as determined by Community Care.

If we deny your request for changes, we will deny it in writing. The denial will have the reasons and will tell you how to file a complaint if you do not agree with the denial.

• Request an Accounting of Disclosures: You have the right to request an accounting of some disclosures of your health information. This is a list of how Community Care has shared your information or how others have done so on our behalf. The list will not include the sharing we have done for treatment, payment and health care functions. It also does not include sharing that you authorized in writing. There may be other exceptions.
  • You must request a list of disclosures in writing. The request must give us a time frame starting after April 13, 2003. The time frame must be within six years from the date of your request. The first accounting you ask for in a 12-month period is free. For more requests, we may charge you our costs.

• Request Limits: You have the right to ask for limits on how we use or share your health information for treatment, payment, or health care functions. You can send us a written form to limit the level of information we share and the people with whom it is shared. You can also request limits on the health information we share about you with a family member, friend or other person who is involved in your care.
  • We are not required to agree to your requests to limit how we use your health information within Community Care. We will grant requests to limit use of health information within Community Care if the request is sound and acceptable. If we agree to accept your limits, we will follow your request, except as needed for emergencies. We will limit sharing information outside Community Care, except for information required by the federal and state programs that oversee Community Care.

• Request Private Contacts: You can request that we only contact you about your health care in a certain manner. We will grant to your reasonable requests.

• File a Complaint: If your privacy rights have been violated or hindered, you can complain to Community Care (in person, on the phone, or in writing). We will not retaliate against you if you file a complaint. To file a complaint to Community Care, contact any member of your Team. You may also send a complaint in writing to the Office for Civil Rights. Contact information is below.

NOTE: STATE LAWS MAY HAVE MORE WAYS TO PROTECT PSYCHIATRIC AND SUBSTANCE ABUSE TREATMENT AND HIV-RELATED INFORMATION.

Equal Opportunity Information

Community Care is an equal opportunity employer and service provider.  If you need special assistance to access this material in an alternate format or need it to be translated to a different language, please call (414) 385-6600, Voice; or (414) 385-6626, TTY.

Community Care es una agencia que ofrece igualdad de oportunidad de empleo y servicios. Si usted necesita esta información en un formato alterno ó en un idioma diferente, por favor comuniquese con nosotros al (414) 385-6600, Voz; ó (414) 385-6626, TTY.

"Community Care yog ib tus tswv hauj lwm thiab yog ib qhov chaw pab cuam uas muab vaj huam sib luag rau sawv daws. Yog koj xav tau kev pab kom muab cov ntaub ntawv no pauv ua hom ntawv uas koj to taub los yog xav kom muab txhais ua lwm yam lus, thov hu rau (414) 385-6600, Suab; los yog (414) 385-6626, TTY."

CONTACTING COMMUNITY CARE...

If you want to file a complaint, ask any questions about this Notice, or request more information about your privacy rights, please talk to your Team Social Worker or contact Community Care.

Address:	Community Care, Inc.
	1555 South Layton Boulevard
	Milwaukee, WI 53215
Telephone:	(414) 385-6600
Toll-Free:	(866) 992-6600
TTY:	(414) 385-6626

CONTACTING THE OFFICE FOR CIVIL RIGHTS...

CHANGES TO THIS NOTICE...

Community Care reserves the right to change this Notice and to make the revised or new Notice provisions take effect for all health information already received and held by Community Care as well as for all health information we receive in the future. We will send a copy of the revised Notice to you upon request.