Privacy Statement

This form provides you the advice required by the privacy act of 1974. 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 and Whether Disclosure is Mandatory or Voluntary. Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.
   Medicare and Medicaid participating long term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident’s functional capacity and health status. To implement this requirement, the facility must obtain information from every resident. This information also is used by the Federal Centers for Medicare & Medicaid Services (CMS) to ensure that the facility meets quality standards and provides appropriate care to all residents. For this purpose, as of June 22, 1998, all such facilities are required to establish a database of resident assessment information, and to electronically transmit this information to the CMS contractor in the State government, which in turn transmits the information to CMS. Because the law requires disclosure of this information to Federal and State sources as discussed above, a resident does not have the right to refuse consent to these disclosures. These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records.
   
   
2. Principal Purposes for Which Information is Intended to be Used
   The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services.
   
   
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:
   1. A congressional office from the record of an individual in response to an inquiry from the congressional made at the request of that individual;
   2. The Federal Bureau of Census;
   3. The Federal Department of Justice;
   4. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability, or the restoration of health;
   5. Contractors working for CMS to carry out Medicare/Medicaid functions, collating or analyzing data, or to detect fraud or abuse;
   6. An agency of a State government for purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State;
   7. Another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse;
   8. Quality Improvement Organizations to perform Title XI or Title XVIII functions;
   9. Another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions.
      
      
4. Effect on Individual of not Providing Information
   The information contained in the Long Term Care Minimum Data Set is generally necessary for the facility to provide appropriate and effective care to each resident. If a resident fails to provide such information, for example on medical history, inappropriate and potentially harmful care may result. Moreover, payment for such services by third parties, including Medicare and Medicaid, may not be available unless the facility has sufficient information to identify the individual and support a claim for payment.

NOTE: Providers may request to have the Resident or his or her Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required. If the Resident or his or her Representative agrees to sign the form it merely acknowledges that they have been advised of the foregoing information. Residents or their Representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions.