Eastersealsok.org

Re: ___________________________________________________________ Enclosed please find a copy of Physicians Orders from Easter Seals Adult Day Health Center. Although we are not a nursing facility providing 24 hour care, we do provide medical supervision of our clients’ needs while they are with us during the day. All participants must have their Physician’s Orders to attend our center so we may formulate a complete care plan for each Please complete the attached orders specifically for your patient’s needs, sign them and fax back to (405) 239-2401 when EASTER SEALS ADULT DAY HEALTH CENTER
PHYSICAL EXAMINATION & ORDERS
Participant Name:__________________________________DOB:__________
Ht:_____ft.____in. Wt._______lbs. B_______ (Range _____to______) Allergies: Medication:________________________ Food:___________________ MEDICAL DIAGNOSIS:
1.__________________ 2._________________ 3.___________________ 4.__________________ 5._________________ 6.___________________ PHYSICAL EXAMINATION:
TEETH: Edentulous _____ Own Teeth_____ Dentures: Y / N Upper _____Lower_____ VISION: good_____ fair_____ poor_____ Glasses: Y / N HEARING: good____ fair ____poor _____ Hearing Aide: Y / N LUNGS: ___________________________ HEART: ___________________________
GI:___________ Constipation_________ Diarrhea___________ Incontinence________ URINARY:____________________ Chronic UTI ____________ Incontinence_______ EXTREMITIES:_____________ Edema ___________ Skin Condition _____________ MENTAL STATUS:
Memory Loss: Y / N Short term: __________ Long term: _______________ Dementia: Y / N Type ________________ Stage __________________ Depression: Y / N Anxiety_______________ Other__________________ Physician’s Printed Name: _____________________________
Physician’s Signature______________________________Date____________
PHYSICIAN’S ORDERS
Please check any over-the-counter medications that may be given to your patient at the discretion of licensed personnel: _______ Maalox 1000 mg. tab or liquid q 4 hr pm indigestion _______ Tylenol 325 / 500 mg. 1 or 2 tabs q 4-6 hrs pm pain or elevated temp _______ Imodium AD 1 caplet after each loose stool x2 pm diarrhea _______ OTC throat lozenges 1 for sore throat or cough pm every hour x3 Other: ____________________________________________________________ Date of last influenza injection _________________________________________ If diabetic- FSBS pm: Yes _____No______ (Normal Range: ) _________ DIET: (No added salt diet provided at the Center) _______Limit Concentrated Sweets Vulnerable to wt. loss: Y / N Chewing difficulties: Y / N Swallowing difficulties: Y / N ACTIVITY LEVEL: Full_______ Limited ________Explain _____________________ Assistive Devices: ______Cane _______Walker _______ Wheelchair _______Braces Fall Risk: Y / N PT Evaluation/Treat: Y / N ADVANCE DIRECTIVE _________________DNR: ______________ Physician’s signature _____________________________Date: _______________ Print Name: ________________________________________________________ Address: ________________________________________________________ Telephone: __________________________Fax: __________________________ Easter Seals Adult Day Health Center
Easter Seals Adult Day Health Center (ADHC) will not enroll any person whose needs exceed the capability of the program. Persons whose needs cannot realistically be met by the planned program of the ADHC will not be enrolled. I understand that my acceptance into the Easter Seals ADHC program is provisional and that I will be evaluated for 10 days at the ADHC by the staff of the program for appropriateness of this program. If I do not respond to the program; have some behavior that interferes with the operation of the Easter Seals Adult Day Center; or it becomes evident that I have a physical or mental condition that requires another level of care, I understand I will not be allowed to continue the program. Race, color, religion, gender, national origin, marital status, and/or payor source shall not affect the ADHC decision to admit for services. The Easter Seals Adult Day Health Center program uses the following criteria as admission guidelines for admittance to the program. Participant must be able to assist with transfers. Participant must be able to feed self, after preparation and set-up of food. Participant must be continent of stool. If incontinent of urine, they agree to wear Attends, pads or other effective undergarments. Participant must be able to sit up for lengths of time at the ADHC. Must have control over seizures. Participant cannot be physically abusive to others, nor exhibit repeated/uncontrolled verbal abuse, or be sexually inappropriate. I have read these admission requirements, and to my knowledge, (Participant’s name) _______________________________currently meets the admission criteria of the Easter Seals Adult Day Health Center and will be able to participate in their program. ______________________________________ _________________ Participant/Caregiver/Guardian Easter Seals Adult Day Health Center
701 NE. 13th Oklahoma City, OK 73104
Phone: (405)239-2525 Fax: (405)239-2278
ARRIVAL/DEPARTURE INFORMATION
Participant: __________________________________________________________________ Phone # of residence where participant will be transported from: ________________________ Scheduled Day of Participation: Monday _________________ Wednesday _______________ Thursday ________________ Friday ___________________ Regular Arrival Time: ________________________ Regular Departure Time: _______________________ I authorize the following individuals to transport above participant due to illness, disruptive behavior, or non-arrival of caregiver (proof of identity may be required before participant will be released): 1. Name: ________________________________________ ________________________________________ ________________________________________ Relationship: ________________________________________ _________________________________________ _________________________________________ _________________________________________ Relationship: _________________________________________ ________________________________________ Participant/Caregiver/Guardian Signature Easter Seals Adult Day Health Center
701 NE 13th Oklahoma City, OK 73104
Phone: (405)239-2525 Fax: (405)239-2278
Authorization for Release of Medical Information
Name: ____________________________SS# ________________________ DOB: ____/____ /________ Male _______ The purpose or need for this disclosure: ______________________ _____ This authorizes the below named physician, hospital or other organization, agency or person having medical, health, social or economic records, data or information concerning the above identifies participant to furnish such records as may be required on my behalf by the Easter Seals Adult Day Health Center (ADHC) This also authorizes the ADHC to furnish medical, health, social or economic records, data, or information concerning the above identified applicant to the below named physician, hospital or other organization, agency, or person having need for such information. The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not be limited to, diseases such as Hepatitis, Syphilis, Gonorrhea, and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS). These records may also indicate information about usage of or addiction to chemical substances such as alcohol or drugs. I understand that I may ask questions, consult with anyone and review these records before I sign this form. The facility, its employees and attending physician are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein. Name: A photocopy of this authorization shall be considered as effective and valid as the original. Signature: Easter Seals Adult Day Health Center
Confidentiality Guidelines
1. All participant records will be kept and treated with strict confidentiality. 2. Participant charts will be kept stored in a locked file cabinet. 3. All Easter Seals staff will sign confidentiality agreements as an employment requirement. 4. Participant records will be available only to Easter Seals Adult Day Health Center staff or other 5. The participant, or their representative, must sign authorization for release of information to and from the Easter Seals Adult Day Health Center, before any information will be released or requested. 6. Participants are not discussed in the presence of other participants or any unauthorized persons. 7. No information concerning individual clients will be displayed in areas accessible to the public 8. Forms or documents containing participant information will be maintained in the ADHC for at least five (5) years following termination of enrollment by the participant and then disposed of appropriately as confidential information. I have read and accept the Easter Seals Adult Day Health Center Confidentiality Guidelines. Participant/Caregiver/Employee/Volunteer Easter Seals Adult Day Health Center
Contract for Services
Participant: ___________________________________ Phone:___________________

Address: _______________________________________________________________

Person responsible for payment if different than above:
Name: __________________ Relationship: _______________ Phone: _____________

Address_: _______________________________________________________________

Fee for Services:
I am entering into an agreement of participation with the Easter Seals Adult Day Health Center
in Oklahoma City, OK. I have been informed that the private pay fee for services is $60 per day.
An hourly rate of $10.00 is paid for attendance of less than 6 hours a day. This fee includes the cost
of meal service.

Department of Human Services, Veterans Administration, and Advantage Waiver:
Fee for services is determined by the agency. DHS qualifies individuals based on their income.
Co-payment amounts are determined by the DHS county office after an application is
submitted. Transportation fees are covered by the above agencies.

I understand that the Easter Seals Adult Day Health Center relies on participant fees to cover
the cost of care and services. A bill will be mailed at the beginning of each month for the
previous month’s services. Checks should be made out to Easter Seals. They may be mailed
to:
Easter Seals Adult Day Health Center
701 NE 13th
Oklahoma City, OK 73104
_________________________________________ _____________________
Person Responsible for Payment
Date


_________________________________________ ______________________
Intake
Worker
Date
Easter Seals Adult Day Health Center
Emergency Information

IN CASE OF A MEDICAL EMERGENCY: I AUTHORIZE THE ADULT DAY CENTER TO SECURE
AND OBTAIN PROPER MEDICAL TREATMENT ON MY BEHALF. IF IN NEED OF AN
EMERGENCY VEHICLE, I GIVE THE ADS PERMISSION TO USE OU MEDICAL CENTER
AMBULANCE SERVICE.

Easter Seals Adult Day Health Center
GENERAL RELEASE OF LIABILITY
I would like to attend the Easter Seals Adult Day Health Center and participate in the daily program. My participation is voluntary and I release and agree to hold harmless the Easter Seals Adult Day Health Center, its employees, volunteers, and agents from any and all liability and responsibility (unless proximately caused by the willful misconduct of any of the above mentioned) for or relating to any illness, accident, or other event which may occur while I am a participant in the program. Participant: Easter Seals Adult Day Health Center
INTAKE MEDICAL ASSESSMENT
Number of doctor visits in the past year? Number of days spent in the hospital in the past year? Current Medical Status and History
Eyesight:
Glasses:
Hearing:
Hearing Aid:
Yes (L/R/B)
Need (L/R/B)
Edentulous
Dentures Upper/Lower/Need)

Ambulation:
Assist x1
Assist x2
Unable to bear weight
Health Conditions: (Past or Present)
Alcohol/Substance Abuse
Alzheimer’s or other dementia
Anemia/bleeding disorders
Arthritis/rheumatism
Bladder: Continent/Incontinent/Dribble
Bowel: Continent/Incontinent
Cancer or leukemia
Cataracts
Circulation problems
Diabetes
Difficulty with food, chewing
Emphysema: COPD, Asthma, Bronchitis
Epilepsy/Seizure Disorder
Falls/Recent History of
Glaucoma
Heart trouble, CHF
High/low blood pressure
Hostile: Withdrawn/ Depression
Liver disease
Mental Retardation
Parkinson’s disease
Skin disorders; pressure sores, leg ulcers, burns
Stomach: intestinal disorders
(Diarrhea or constipation)
Stroke
Thyroid or other glandular problems
Tuberculosis
Urinary tract disorders
Wanders
Other Illness, disabilities or injuries:
(page 2) Any family history of the above mentioned health conditions? If yes, please specify which conditions and the relationship to participant: Current Medication _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ List _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ List other non-surgical hospitalizations: Reason _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Are any of the following in effect: Power of Attorney: _______________________________________________________________ Program _______________________________________________________________ Program Easter Seals Adult Day Health Center
MEDICATION ADMINISTRATION PROCEDURES
It is understood that the Adult Day Health Center and its staff will not be responsible for any adverse effects related to the administration of any medication. I, authorize the Adult Day Health Center to administer any/all medications, to be taken by while attending the ADHC, and agree to provide the necessary dosages of these medications. 1. Only a licensed staff member will give any and all medications, including over-the- counter and prescription, during attendance at ADS. 2. Medication brought to the facility must be in a pharmacy bottle with proper pharmacy label or in the original bottle if a non-prescription medication. 3. ADHC must have doctor’s orders for all medications. 4. Medicine bottle label must match the doctor’s orders given to facility. 5. If participant is discharged, the medicine must be taken home upon discharge. 6. If participant stops coming to the ADHC, we will send One (1) letter home advising the family to pick up all medications. If medication is still on site one (1) week after letter has been mailed, it will be destroyed, per facility policy. 7. If participant should pass away during enrollment at the ADHC, all medications will be EASTER SEALS ADULT DAY HEALTH CENTER
NOTICE OF PRIVACY PRACTICES
You have the right to receive a notice of our privacy practices with respect to your medical and billing information. You signature here indicates that you have received a copy of our Notice of Privacy Practices. Easter Seals Adult Day Health Center Representative Easter Seals Adult Day Health Center
OUTING PERMISSION
give the Adult Day Health Center permission to transport on outing whenever weather and conditions permit them to do so. These outings will include trips to the lake, parks, civic and cultural centers and other places of interest in and around the Oklahoma City metro area. I understand that my signature authorizes blanket permission to be used in the Oklahoma City metro area. Any lengthy trips will require my signature on a specific document giving my permission for the trip. This specific document will state the whereabouts of such an outing. The Adult Day Health Center will see that all safety precautions and quality care will be provided to the best of their ability at all times. Participant/Caregiver/Guardian Signature Date: In case of emergency please notify: Name: Easter Seals Adult Day Health Center
Where have you spent most of your life? Farm or City To what organizations have you belonged? Easter Seals Adult Day Health Center
PARTICIPANT’S RIGHTS
Each participant of the Adult Day Health Center shall be assured of the following rights: 1. To be treated as an adult, with respect and dignity regardless of race, color or creed. 2. To participate in a program of services and activities which promote positive attitudes regarding ones usefulness and capabilities. 3. To participate in a program of services designed to encourage learning, growth, and awareness of constructive ways to develop ones interests and talents. 4. To maintain ones independence to the extent that conditions and circumstances permit; and to be involved in a program of services designed to promote independence. 5. To be encouraged to attain self-determination within the adult day center setting, including the opportunity to participate in developing ones care plan for services, to decide whither or not to participate in any given activity, and to the extent possible, in program planning and operation. 6. To be cared for in an atmosphere of sincere interest and concern in which needed 7. To have privacy and confidentiality. (HIPAA Guidelines) 8. To be free of mental and physical abuse. 9. To be free of restraint unless under physician’s order as indicated on the individual 10. To have access to telephone to make or receive calls, unless necessary restrictions are indicated in the individual care plan. 11. To be free of interference, coercion, discrimination or reprisal.
I HAVE READ THESE RIGHTS (or have had them read to me) AND UNDERSTAND
EACH OF THEM.

Easter Seals Adult Day Health Center
Phone: (405) 239-2525 Fax: (405) 239-2278 PHOTOGRAPH AND VOICE CONSENT
I authorize taking my picture by photograph, movie, and/or videotape, and/or the recording of my voice by the Adult Day Health Center staff or persons authorized by the ADHC, while participating in the Adult Day Health Center program. Furthermore, I consent to and authorize the use and reproduction of any and all photographs, movies, videotapes, including prints, negatives, and positives, or sound recordings which they have taken of me or arranged to have taken for publicity, education or informational purposes, without compensation to me. All prints, negatives, positives and sound recordings shall remain the sole property of the Adult Day Health Services. I understand that my refusal of consent for photographs or voice release will in no way affect my eligibility for the services of the ADHC or the care I receive as a participant in the ADHC. Easter Seals Adult Day Health Center
TERMINATION of SERVICES
1. Participant has an acute illness which the ADHC is unable to properly cope with. 2. Participant has a communicable disease. 3. Participant requires constant supervision by a nurse or program staff. 5. Participant exhibits repeated and uncontrolled verbal abuse. 6. Participant is sexually inappropriate. 7. Participant requires care and services, which the ADHC staff is unable to provide due to advanced medical, physical or psychosocial problems. 8. Participant has an outstanding bill of 30 days. 9. Abuse of services (ex. Late in picking up participant; not ready for pick-up, etc.). 10. Non-compliance with requirements for admission &continual enrollment. 11. Participant poses a danger to self or others. 12. Any problem considered to be disruptive to program as determined by Director/Program Nurse. DISCHARGE PROCEDURES: Once admitted to the program and a discharge becomes necessary, the family member and/or caregiver will be notified by the Program Director or designee by letter/telephone, and a discharge plan will be suggested for the individual participant. Race, color, religion, gender, national origin, marital status, and/or payers’ source shall not affect the ADHC decision to terminate services. STATEMENT OF UNDERSTANDING: I have read the termination criteria for the Adult Day Health Center program. I agree to give the Program Director of the ADHC full discretion in termination services, if the participant, in the opinion of the Program Director and program staff, meet any one of the criteria for termination at any time during his/her stay at the Adult Day Health Center. Easter Seals Adult Day Health Center
Client’s Name: ____________________________________________________ Pet Therapy Dog Visitation
I, _______________________, give my permission for ___________________
_____________________ to participate in dog therapy visitations at
Easter Seals Adult Day Health Center.
I understand that a certain amount of risk is involved whenever an animal is present. I
also understand that the dogs providing visitation have completed the series of
requirements mandated by the State Health
Department.
Signature of responsible party: ________________________________________
Late Departure Policy
Easter Seals Adult Day Health Center Hours are 7:30 a.m. until 5:30 p.m.
Monday through Friday. Clients must depart the premises no later than 5:30 p.m.
An additional $2.00 per minute charge will be billed to the Client’s responsible party for
every minute exceeding 5:30 p.m. Late charges will be included in a monthly billing.
Failure to pay charges in a timely manner may result in termination from the program.
Social Services is available to assist with community resource information upon
request.
I understand Easter Seals Adult Day Health Center will charge$2.00 per minute Following 5:30 p.m. I have read the policy and agree to comply. __________________________________ 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.
If you have any questions about this Notice please contact: Vida Wasinger This Notice of Privacy Practices describes how we may use and disclose protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, your protected health information may be used and disclosed by your therapist or caregiver, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and our services. Payment: Your protected health information will be used, as needed, to obtain payment for your health care
services. This may include certain activities that your health insurance plan may undertake before it approves or
pays for the health care services we recommend for you such as; making a determination of eligibility or
coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking
utilization review activities.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to
support the business activities of our operation. These activities include, but are not limited to, quality
assessment activities, employee review activities, licensing, and fundraising activities.
We will share your protected health information with third party “business associates” that perform various activities for our organization. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address may be used to send you a newsletter about the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent,
Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, we may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your protected health information that directly relates to
that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may
disclose such information as necessary if we determine that it is in your best interest based on our professional
judgment. We may use or disclose protected health information to notify or assist in notifying a family member,
personal representative or any other person that is responsible for your care of your location, general condition
or death. Finally, we may use or disclose your protected health information to an authorized public or private
entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals
involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If
this happens, your therapist or caregiver shall try to obtain your consent as soon as reasonably practicable after
the delivery of treatment. If your therapist/caregiver has attempted to obtain your consent but is unable to obtain
your consent, he or she may still use or disclose your protected health information to treat you.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent,
Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or
disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited
to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a
public health authority that is permitted by law to collect or receive the information. The disclosure will be made
for the purpose of controlling disease, injury or disability. We may also disclose your protected health
information, if directed by the public health authority, to a foreign government agency that is collaborating with
the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person
who may have been exposed to a communicable disease or may otherwise be at risk of contracting or
spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities
authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information
include government agencies that oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is
authorized by law to receive reports of child abuse, adult abuse or neglect. In addition, we may disclose your
protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to
the governmental entity or agency authorized to receive such information. In this case, the disclosure will be
made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company
required by the Food and Drug Administration to report adverse events, product defects or problems, biologic
product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct
post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such
disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other
lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal
processes and otherwise required by law, (2) limited information requests for identification and location
purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal
conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on
the Practice’s premises) and it is likely that a crime has occurred.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health
information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. We may also disclose protected health information if it is
necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose
protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary
by appropriate military command authorities; (2) for the purpose of a determination by the Department of
Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that
foreign military services. We may also disclose your protected health information to authorized federal officials
for conducting national security and intelligence activities including for the provision of protective services to the
President or others legally authorized.
Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply
with workers’ compensation laws and other similar legally-established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate or determine our compliance with the
requirements of Section 164.500 et. seq.

2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect
and obtain a copy of protected health information about you that is contained in a designated record set for as
long as we maintain the protected health information. A “designated record set” contains medical and billing
records and any other records that your caregiver/therapist uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact in you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask
us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or
healthcare operations. You may also request that any part of your protected health information not be disclosed
to family members or friends who may be involved in your care or for notification purposes as described in this
Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the
restriction to apply.
We are not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure or your protected health information, your protected health information will not be restricted. If your caregiver/therapist does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you may request with your caregiver/therapist. You may request a restriction by presenting a written request listing the restriction to our Privacy Contact. You have the right to request to receive confidential communications from us by alternative means or at
an alternative location. We will accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will be handled or specification of an
alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to
accept this notice electronically.
3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Contact, Vida Wasinger, at (405) 239-2525 or email vwasinger@eastersealsoklahoma.org for further information about this complaint process. This notice was published and becomes effective on April 14, 2003.

Source: http://eastersealsok.org/downloads/Application%20Adult%20Day_2011.pdf