Notice of Privacy Practices

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.  You have the right to obtain a paper copy of this Notice upon request.

Consumer Health Information

This notice will tell you how we may use and disclose protected health information about you.  Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you.  In the header above, that information is referred to as “medical information.”  In this notice, we simply call all of that protection health information, “health information”.  This notice also will tell you about your rights and our duties with respect to health information about you.  In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.  Under federal law, your health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information.  Your health information also includes payment, billing, and insurance information.

How We Use Your Health Information

We use health information about you for treatment, to obtain payment, and for health care operations, including administrative purposes and evaluation of the quality of care that you receive.  Under some circumstances, we may be required to use or disclose the information even without your permission.

Examples of Treatment, Payment, and Health Care Operations


We may use health information about you to provide, coordinate, or manage the services, supports, and health care you receive from us and other providers.  We may disclose health information about you to doctors, nurses, qualified mental retardation professionals (QMRP), psychologists, social workers, direct support staff and other agency staff, volunteers and other persons who are involved in supporting you or providing care.  We may consult with other health care providers concerning you and, as part of the consultation, share your health information with them.  For example, staff may discuss your information to develop and carry out your individual service plan.  Staff may share information to coordinate needed services, such as medical test, transportation to a doctor’s visit, physical therapy, etc.  Staff may need to disclose health information to entities outside of our organization (for example, another provider or a state/local agency) to obtain new services for you.  We may disclose the information to other health care providers who are filling your prescriptions, and to guardian/parents who are helping with your care.


We may use and disclose health information about you so we can be paid for the services we provide to you.  This can include billing a third party payor, such as Medicaid or other state agency (for example, the state’s Department of SRS), or your insurance company.  For example, we may need to provide the state Medicaid program information about the services we provide to you so we will be reimbursed for those services.  We also may need to povide the state Medicaid program information to ensure you are eligible for the medical assistance program.

Health Care Operations

We may use and disclose health information about you for our own operations.  These are necessary for us to operate Twin Rivers Developmental Supports, Inc. and to maintain quality for our consumers.  For example, we may use health information about you to review the services we provide and the performance of our employees supporting you.  We may disclose health information about you to train our staff and volunteers.  We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program.

Health Related Benefits and Service Alternatives

We may use and disclose health information about you to contact you about health-related benefits and services that may be of interest to you.

Disclosures to Family and Others

We may disclose to a parent/guardian or any other person identified by you, health information about you that is directly relevant to that person’s involvement with the services and supports you receive or payment for those services and supports.  We also may use or disclose health information about you to notify, or assist in notifying, those persons of your location, general condition, or death.

Disaster Relief

We may use or disclose health information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.  This will be done to coordinate with those entities in notifying a parent/guardian or other person identified by you of your location, general condition or death.

Other Uses and Disclosures

We may use or disclose identifiable health information about you for other reasons, even without your consent, subject to certain requirements, we are permitted to give out health information without your permission for the following purposes:

Required By Law

We may be required by law to report suspected abuse, neglect, exploitation or similar injuries and events.

Public Health Activities

As required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public health authorities.

Health Oversight

We may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions.  These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.

Judicial and Administrative Proceedings

We may disclose information in response to an appropriate subpoena or court order.

Law Enforcement Purposes

Subject to certain restrictions, we may disclose information required by law enforcement officials.


We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ donation agencies.

Serious Threat To Health Or Safety

We may use and disclose information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military and Special Government Functions

If you are a member of the armed forces, we may release information as required by military command authorities.  We may also disclose information to correctional institutions for national security purposes.

Workers Compensation

We may release information about you for workers compensation or similar programs providing benefits for work-related injuries or illness.

In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you.  If you choose to sign an authorization to disclose information, you can later revoke that autohirzation to stop any future uses and discloses.

Individual Rights

You have the following rights with regard to your health information.  Please contact the person listed below to obtain the appropriate form for exercising these rights.

Request Restrictions

You may request restrictions on certain uses and disclosures of your health information.  We are not required to agree to such restrictions, but if we do agree, we must abide by those restrictions.

Confidential Communications

You may ask us to communicate with you confidentially by, for example, sending notices to a special address or not using postcards to remind you of appointments.

Inspect And Obtain Copies

In most cases, you have the right to look at or get a copy of your health information.  There may be a small charge for copies.

Amended Information

If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct the existing information or add the missing information.

Accounting of Disclosure

You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or health care operations.

Our Legal Duty

We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect.

Changes In Privacy Practices

We may change our policies at any time.  Before we make a significant change in our policies, we will change our Notice and post the new Notice in the consumer lunch area.  You can also request a copy of our Notice at any time.  For more information about our privacy practices, contact the person listed below.


If you are concerned that we have voilated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below.  You also may send a written complaint to the U.S. Department of Health and Human Services.  The person listed below will provide you with the appropriate address upon request.  You will not be penalized in any way for filing a complaint.

Contact Person

If you have any questions, requests, or complaints, please contact:

Director of Human Resources
P.O. Box 133
Arkansas City, KS 67005
(620) 442-3575

Effective Date: 02/26/03