THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCUSSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

USES AND DISCLOSURE
Sta-home Health Agency will not use or disclose your medical information to any person
without your express written authorization except for purposes which are permitted by law. The
reasons for which disclosure is permitted include:

Treatment - for example, communicating your condition to your doctor for changing your
plan of care or communicating with family, caregivers and friends involved
in your plan of care.
Payment - for example, providing an insurance company evidence of services rendered to
you
Health Care Operations - for example, reviewing documentation of services rendered for
quality control purposes
Compliance with reporting requirements of Mississippi's Vulnerable Adults Laws
Court Order
Surveys
Prevention of harm to you or others
Order of Federal or State Authorities

If you authorize disclosure for any other purpose, you may revoke such authorization at your discretion
at any time.

YOUR RIGHTS

Restrictions - you have the right to request restrictions on uses and disclosures that are
permitted by law. Sta-home has no obligation to agree to the requested restrictions.

Communications - you have the right to request Sta-home to communicate with you by
alternate means or at alternate places and Sta-home must accommodate such reasonable requests.

Inspection - you have the right to inspect and copy your medical records except for
psychotherapy notes, information separately compiled for litigation purposes or separately obtained
under a promise of confidentiality, and except for access that is barred by law. Access may also be
denied if Sta-home has reason to believe that access may endanger you or another person. If access is
denied for safety reasons, you have the right to have that decision reviewed by an independent health
care professional designated by Sta-home for that purpose.

Amendment - you have the right to request additions to or the correction of errors in medical
records created by Sta-home. If your request is not granted within 60 days, Sta-home must provide
you a written explanation of its reasons for not acting upon your request and any subsequent rights you
may have.

Accounting - you have the right to receive an accounting of all unauthorized disclosures and
disclosures required by law including the date of the disclosure, the name of the recipient and a brief
description of the disclosure.

Complaints - you have the right to file a complaint, without fear of retaliation, if you believe
your primary rights have been violated. A complaint may be filed with Sta-home's Privacy Officer, at
406 Briarwood Drive Bldg 200, Jackson, MS 39206 [601- 956- 5100] or with the Secretary of the Department
of Human Services 200 Independence Ave. S.W. Washington D.C. 20201.

STA-HOME'S DUTIES
Sta-home has the duty to maintain the privacy of your protected health information through
reasonable physical, administrative and technical safeguards, as well as through the training and
discipline of Sta-home personnel. Sta-home must also make reasonable efforts to mitigate any breach
of privacy.