PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE
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 MANDTORY 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 merely acknowledges that you have been advised
of the foregoing. If requested, a copy of this form will be
furnished to you.
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