District Three Governmental Cooperative

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	Comprehensive Notice of Privacy Practices District Three Governmental Cooperative Effective Date -- April 15, 2003 This notice describes how personal information about you may be used and tells how you can get a copy of this information. Please read it carefully. If you have any questions about this Notice or need someone to read it or explain it to you, please call 1 (800) 541-0933. District Three Governmental Cooperative must keep your personal records private. It is the law and it is your right. We are also required to let you know when there are changes in our Privacy Practices. The law lets us share your records with other agencies that may be able to provide you with services or help us determine your eligibility for services. This paper tells you who we may share your personal records with, what your rights are, and how you can make a complaint if you think your rights have not been protected. When you first ask for help, we write your name, age, Social Security number, address, and other personal information in a file. Every time you receive services, we will write in your file what we did to take care of you. This file is known as "confidential personal information." The following pages explain how we can use your personal information and when we can share it with others. Sometimes, for example, we may have to share information with other agencies so you can get the help you need. We may have to share the information with another organization so payment for your care can be made. 1. SHARING OF PROTECTED PERSONAL INFORMATION Sharing Personal Information Based Upon Your Written Permission You will be asked to sign a Uniform Consent to Exchange Information when you apply for services. Once you have signed the permission form, we will only use or share your protected personal information to determine your eligibility for services and to provide you with those services for which you are eligible. We may share personal information about you to other agencies who can help us determine eligibility or who are involved in providing the services you need. Ways We May Share Your Personal Information Without Your Permission We may use or share your protected personal information in the following situations without your permission: · If it is Required By Law: If we share information it will be limited to what the law says we have to share. We will tell you if the law says we have to share your personal information with someone else. · In Emergencies: We may share your protected personal information in an emergency situation in which the information will assist the rescue squad, fire department, police/sheriff, or emergency room staff in providing you with emergency care. · If You Cannot Speak English: We may share your protected personal information if you are unable to talk with us because you cannot read or understand English or are otherwise unable to talk with us. For example, we may have to ask other members of your family to provide us with information. · If We Believe You Have Been Abused, Exploited, or Neglected: If we believe that you have been the victim of abuse, neglect, or domestic violence we are required by law to tell the local Department of Social Services. · In the Event of Legal Proceedings: We may share protected personal information if the court tells us we have to share it. 2. YOUR RIGHTS You have the following rights regarding personal information about you that we keep in our files: Right to See and Copy. You have the right to see and have a copy of any personal information that we use to make decisions about your services. To see and have a copy of your personal information, you need to contact your caseworker. If you ask for a copy of your information, we may charge a small fee for the cost of copying or mailing the information. We may deny your request to see and copy information in certain very limited situations. If we refuse to let you see or copy personal information, you may appeal. Your worker will explain this to you. Right to Make Changes. If you feel that personal information about you in our files is wrong, you may ask us to change the information. You have the right to ask for a change as long as the information is kept by us. To request a change, contact your worker. We may not make the changes you ask if the information: · Was not collected by us; · Is not part of the personal information normally kept by us; · Is not part of the information which you would be allowed to see and copy; or · We believe the information is already accurate and complete. Right to Ask if Any Personal Information Has Been Shared. You have the right to ask us if we have shared any personal information with another organization or agency. You can ask your worker. We are unable to tell you about any information we may have shared before April 14, 2003. Right to Ask Us Not to Share Information. You have the right to ask us not to share personal information with certain persons or organizations. For example, you can ask that we not share information about your income or pension benefits with your relatives. You can ask your caseworker not to share information but you must tell us (1) what information you want us not to share, and (2) who you do not want us to share the information with. If you ask us not to use or share your personal information, we will no longer use or share information about you for the reasons you tell us. You need to understand that we are unable to take back any information we have already shared with your permission, and that we are required to keep this information in our records for the services we have already provided to you. Right to ask for Confidential Communications. You have the right to ask that we only talk with you about the services you receive. For example you can ask that we not send mail to your home if you share the home with others. To request confidential communication, you must tell your worker. We will not ask you the reason for your request. We will try to do what you ask; however, it may not be possible for us to provide you with the services you need if you limit how we can contact you or communicate with you and we are not required to agree to your request. 3. PRIVACY OFFICER The Executive Director of District Three Governmental Cooperative serves as the agency's Privacy Officer. 4. COMPLAINTS If you believe we have shared information that you did not want us to share, you may make a complaint. To make a complaint, call 1 (800) 541-0933 Monday through Friday from 8:30 a.m. to 4:30 p.m., except holidays. Also, you may complain directly to the Secretary of the Department of Health and Human Services. You will not lose your services just because you have made a complaint.

Comprehensive Notice of Privacy Practices
District Three Governmental Cooperative Effective Date -- April 15, 2003

This notice describes how personal information about you may be used and tells how you can get a copy of this information.

Please read it carefully.

If you have any questions about this Notice or need someone to read it or explain it to you, please call 1 (800) 541-0933.

District Three Governmental Cooperative must keep your personal records private. It is the law and it is your right. We are also required to let you know when there are changes in our Privacy Practices. The law lets us share your records with other agencies that may be able to provide you with services or help us determine your eligibility for services. This paper tells you who we may share your personal records with, what your rights are, and how you can make a complaint if you think your rights have not been protected.

When you first ask for help, we write your name, age, Social Security number, address, and other personal information in a file. Every time you receive services, we will write in your file what we did to take care of you. This file is known as "confidential personal information."

The following pages explain how we can use your personal information and when we can share it with others. Sometimes, for example, we may have to share information with other agencies so you can get the help you need. We may have to share the information with another organization so payment for your care can be made.

1. SHARING OF PROTECTED PERSONAL INFORMATION

Sharing Personal Information Based Upon Your Written Permission

You will be asked to sign a Uniform Consent to Exchange Information when you apply for services. Once you have signed the permission form, we will only use or share your protected personal information to determine your eligibility for services and to provide you with those services for which you are eligible. We may share personal information about you to other agencies who can help us determine eligibility or who are involved in providing the services you need.

Ways We May Share Your Personal Information Without Your Permission

We may use or share your protected personal information in the following situations without your permission:

· If it is Required By Law: If we share information it will be limited to what the law says we have to share. We will tell you if the law says we have to share your personal information with someone else.

· In Emergencies: We may share your protected personal information in an emergency situation in which the information will assist the rescue squad, fire department, police/sheriff, or emergency room staff in providing you with emergency care.

· If You Cannot Speak English: We may share your protected personal information if you are unable to talk with us because you cannot read or understand English or are otherwise unable to talk with us. For example, we may have to ask other members of your family to provide us with information.

· If We Believe You Have Been Abused, Exploited, or Neglected: If we believe that you have been the victim of abuse, neglect, or domestic violence we are required by law to tell the local Department of Social Services.

· In the Event of Legal Proceedings: We may share protected personal information if the court tells us we have to share it.

2. YOUR RIGHTS

You have the following rights regarding personal information about you that we keep in our files:

Right to See and Copy. You have the right to see and have a copy of any personal information that we use to make decisions about your services. To see and have a copy of your personal information, you need to contact your caseworker. If you ask for a copy of your information, we may charge a small fee for the cost of copying or mailing the information.

We may deny your request to see and copy information in certain very limited situations. If we refuse to let you see or copy personal information, you may appeal. Your worker will explain this to you.

Right to Make Changes. If you feel that personal information about you in our files is wrong, you may ask us to change the information. You have the right to ask for a change as long as the information is kept by us. To request a change, contact your worker. We may not make the changes you ask if the information:

· Was not collected by us;

· Is not part of the personal information normally kept by us;

· Is not part of the information which you would be allowed to see and copy; or

· We believe the information is already accurate and complete.

Right to Ask if Any Personal Information Has Been Shared. You have the right to ask us if we have shared any personal information with another organization or agency. You can ask your worker. We are unable to tell you about any information we may have shared before April 14, 2003.

Right to Ask Us Not to Share Information. You have the right to ask us not to share personal information with certain persons or organizations. For example, you can ask that we not share information about your income or pension benefits with your relatives. You can ask your caseworker not to share information but you must tell us (1) what information you want us not to share, and (2) who you do not want us to share the information with.

If you ask us not to use or share your personal information, we will no longer use or share information about you for the reasons you tell us. You need to understand that we are unable to take back any information we have already shared with your permission, and that we are required to keep this information in our records for the services we have already provided to you.

Right to ask for Confidential Communications. You have the right to ask that we only talk with you about the services you receive. For example you can ask that we not send mail to your home if you share the home with others.

To request confidential communication, you must tell your worker. We will not ask you the reason for your request. We will try to do what you ask; however, it may not be possible for us to provide you with the services you need if you limit how we can contact you or communicate with you and we are not required to agree to your request.

3. PRIVACY OFFICER

The Executive Director of District Three Governmental Cooperative serves as the agency's Privacy Officer.

4. COMPLAINTS

If you believe we have shared information that you did not want us to share, you may make a complaint. To make a complaint, call 1 (800) 541-0933 Monday through Friday from 8:30 a.m. to 4:30 p.m., except holidays. Also, you may complain directly to the Secretary of the Department of Health and Human Services. You will not lose your services just because you have made a complaint.