ADMISSIONS                                                                                                                                                                                     05-02-004

NEW JERSEY DEPARTMENT OF MILITARY AND VETERANS AFFAIRS

NEW JERSEY VETERANS MEMORIAL HOMES

ACKNOWLEDGMENT OF RESIDENTS’ PRIVACY RIGHTS

Applicant / Resident’s Name____________________________________________________

                                                                                                                                PLEASE PRINT NAME

I,_______________________________________, hereby acknowledge that I have been advised of the reasons for the solicitation and disclosure of personal “Protected Health Information” (“PHI”) pursuant to the Privacy Act, Title 5 U.S.C. § 552a .

1. AUTHORITY. The authority for disclosure of PHI is 45 C.F.R. § 164.502(a). PHI may not be disclosed except with my consent or authorization or as explicitly permitted or required by the regulation.
2. Principal purposes. The principal purposes for disclosing PHI are (1) to the resident; (2) pursuant to a valid consent by the resident that meets the requirements of the above regulation to carry out treatment, payment or healthcare operations; (3) pursuant to a valid authorization of the resident that meets the requirements of the above regulation; (4) pursuant to an agreement under, or as otherwise permitted by the regulation, and as permitted by 45 C.F.R. § 164.502(a)(1); and (5) as required by 45 C.F.R. § 164.502(a)(2).
3. ROUTINE USES. PHI is required to be disclosed (1) to the resident who is the subject of the PHI when the individual requests it; and (2) to the Secretary of Health and Human Services when the Secretary is investigating a complaint or determining a covered entity’s compliance with the regulation. PHI is permitted to be disclosed (3) to the resident him or herself;  and, pursuant to valid consent or authorization of the resident (4) to carry out treatment, payment or healthcare operations; and (5) pursuant to an agreement under, or as otherwise permitted by, the regulation.

Signature:_____________________________________________________________________

[   ] Resident        [   ] Legal Guardian       [   ] Power of Attorney       [   ] Next of Kin

Print Name: ___________________________________________________________________

Date: ________________________________________________________________________

APPLICANT: RETAIN /KEEP THE “NOTICE OF INFORMATION PRACTICES”,

RETURN THIS SIGNED ACKNOWLEDGEMENT FORM WITH YOUR APPLICATION FOR ADMISSION.

Admissions Officer:              File original in Social Services section of medical chart

File copy in Admissions File

Revised: January 2007