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Alpine County’s Health and Human Services Wants to Know: Do You Have a Special Need that someone would need to know about in the event of a Disaster? Dear Alpine County Resident, Hello and thank you for taking the time to read and supply this information. It is very important to the Alpine County Heath and Human Services Department to make sure that all citizens in the county are prepared in the event of a true emergency whether you live here full time, or only come for a vacation. As you know, living in California and living in a rural area, we are used to dealing with disasters on a regular basis. This is especially true in a post 9-11 era with the threat of terrorism and current political situation. Because of this, it is very important that all of us are self prepared for an emergency should the time come. The Alpine County Health and Human Services Department has developed a tool for helping emergency responders quickly locate and identify people who have volunteered their information about a special need and might need assistance in the event of a disaster. This information will be used only for disaster preparedness and response. This does not mean that people should not self prepare in anticipation of an emergency. If you or anyone in your household has any special needs, please fill out this form and return it to the Alpine County Health and Human Services Department. A Special Need could be: • Physical Disability • Mental Disability • Blind or Visually Impaired • Deaf or Hearing Impaired • Frail, Elderly Seniors • Heart Condition • Lung Condition or Asthmatic • Need for Life Sustaining Medications (Diabetic, Seizure, and Allergy Medications) • Oxygen Dependent This is totally voluntary and this confidential information will only be used for disaster preparedness and response. We ask that you and your household still be prepared for a disaster in the event a first responder would not be available right away. We will mail you information on how to prepare you and your family should such an event occur. We also ask that you notify the Health Department if your status should change so that our records are up to date. All of us here at the Health and Human Services Department would like to say thank you for your time and if you have any questions, please feel free to contact us at (530) 694-2146. Alpine County Public Health Officer ---PAGE BREAK--- Special Needs Information Full Name: Daytime Location: Home Work School Day Care (Circle the one that Applies) Senior Care Center Other: Daytime Address: Daytime Phone Number: Daytime Fax Number: Daytime Assessors Parcel Number (if known): Nighttime Location: Home Work School Day Care (Circle the one that Applies) Senior Care Center Other: Nighttime Address: Nighttime Phone Number: Nighttime Fax Number: Nighttime Assessors Parcel Number (if known): Mailing Address: Cell Phone Number: E-Mail Address: Emergency Contact Name: Daytime Phone Number of the Emergency Contact: Nighttime Phone Number of the Emergency Contact: Primary Household Language: Comments: ---PAGE BREAK--- Special Needs Information Diagnosis: Activities of Daily Living: This person has someone with them at all times. This person can be left alone up to This person is alone approximately This person has someone always available to them in an emergency. This person is able to use the phone to call for help, if needed. Client needs help with: Walking • Meal preparation Walks with walker or other device Able to feed self after food is prepared Walks with attendant Needs help with feeding Does not walk, wheelchair bound Bed rest only Bowel/Bladder • Medications Attendant necessary for assistance walking to the bathroom Able to take medications without assistance Bed Rest Only Must have attendant present to take medications Mental State Person is alert at all times Person can be / is always confused and needs supervision Needs Medical Equipment: Bedpan/Urinal Oxygen tank. Size: Constant: As Needed: How long does the tank last: Other (example: suction, • • • Medications: ---PAGE BREAK--- Authorization Alpine County is this person’s primary residence. Alpine County is this person’s secondary residence. I have received a copy of the Notice of Privacy Practices for Alpine County I authorize Alpine County to use the information provided above for emergency and disaster response and planning. In the event of an emergency or disaster, I authorize Alpine County to share this information with other emergency response agencies in order to affect a response. I understand that I have the right to revoke my authorization(s) in writing according to the terms set forth in Alpine County’s Notice of Privacy Practices. The above authorization(s) is/are effective until (fill in the date max. 1 year) Alpine County may not condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization. However, without your authorization, Alpine County is unable to use the specific information that you have provided in this brochure for emergency and disaster response or planning and may not share it with other emergency responders in the event of an emergency or disaster. Signature: Relationship: Legal Disclaimer While it is the goal of the County of Alpine to serve its special needs residents in the event of an emergency, medical crisis, or other similar situation, neither the County nor its Health and Human Services Department make any guarantee or warranty that such services will be provided. Nothing contained in this brochure is intended to or should be construed as creating any obligation or duty on the part of the County, its agents, officers, or employees to provide any special or additional services to those individuals providing the information requested herein, or to the public generally. Mail To: Alpine County Health and Human Services Attn: BT Unit 75B Diamond Valley Road Markleeville Ca. 96120 or Drop this form off at any Alpine County Office Phone: (530) 694-2146 Fax: (530) 694-2252 ACHHS-BT V.2.1 ---PAGE BREAK--- ALPINE COUNTY NOTICE OF PRIVACY PRACTICES This Notice Describes How Health Information About You May Be Used and Disclosed and How You Can Get Access to This Information. Please Review Carefully. Alpine County provides several types of health services including paramedic, mental health, alcohol and drug and public health services. Staff providing these services collect and record information about you in order to provide these services. This information, called “protected health information” (PHI), is protected by Federal and State law. Alpine County is committed to the protection of the privacy of this information. Alpine County May Use and Disclose Information Without Your Authorization in the Following Situations: For Treatment - The Paramedics and staff of the Mental Health and Public Health Programs may use or disclose I information with other health care providers who are involved in your medical treatment. - Information from alcohol and drug treatment records or information about HIV/AIDS status may only be shared between staff providing alcohol and drug services or staff providing HIV services respectively. For Payment Alpine County may use or disclose information to get payment or to pay for the health care services you receive. For example, we may provide PHI to bill your health plan for treatment provided to you. For Health Care Operations We may use or disclose information in order to manage the programs and activities mentioned above. For example, we may use PHI to review the quality of services you receive. For Public Health Activities Alpine County has a public health program that keeps and updates vital records, such as births and deaths and tracks some diseases. This information will be “de-identified” whenever possible so it cannot be personally identified. As Required by Law and For Law Enforcement - Alpine County will use and disclose information when required by federal or state law. - We may also disclose your PHI in response to a court order, subpoena, warrant, summons or other legal requirement. For Reports and Investigation of Abuse Some staff of Alpine County are required by law to report suspected abuse of children and elders and may disclose PHI in making such reports. To Avoid Harm Some staff may be required to disclose PHI in order to warn a victim or alert law enforcement to a threat of violence. Disclosures to Family, Friends and Others - The Paramedics or crisis workers for the Mental Health program may disclose PHI to family or other persons who are involved in emergency medical care in order to facilitate urgently needed treatment. - Information on mental health or alcohol and drug treatment services provided to a minor may be disclosed to the minor’s parents or legal guardian. In All Other Situations, Alpine County May Use and Disclose Protected Health Information Only With Your Authorization, Including The Following: - Disclosure of mental health or alcohol and drug treatment information outside of the treatment program. - Disclosure of personally identifiable information by the Health Department about HIV/AIDS status. Your PHI Privacy Rights Right to See and Get Copies of Your Records. In most cases, you have the right to look at or get copies of your records. You must make the request in writing. You may be charged a fee for the cost of copying your records. This right may be limited in the case of mental health records. Participant Keeps this Page ---PAGE BREAK--- Right to Request Correction or Update of Your Records. You may ask Alpine County to change or add missing information to your records if you think there is a mistake. You must make the request in writing and provide a reason for your request. Alpine County does not have to agree to your request. Right to Get a List of Disclosures. You have the right to ask Alpine County for a list of disclosures of your PHI made in the last six years. However, disclosures made before April 14, 2003 need not be disclosed. You must make the request in writing. This list will not include the disclosures that Alpine County has made subject to your authorization or information to carry out treatment, payment, or health care operations, disclosures made to you, to persons involved in your care, for national security or intelligence purposes, to correctional institutions or law enforcement as required by law, or as part of a limited data set. Right to Request Limits on Uses or Disclosures of PHI. You have the right to ask that Alpine County limit how your information is used or disclosed. You must make the request in writing and tell Alpine County what information you want to limit and to whom you want the limits to apply. Alpine County is not required to agree to the restriction. You can request that the restrictions be terminated in writing or verbally. Right to Revoke Authorization. If you signed an authorization to use or disclose information, you can cancel that authorization at any time. You must make the request in writing. This will not affect information that has already been shared. Right to Choose How We Communicate with You. You have the right to ask that Alpine County share information with you in a certain way or at a certain address. For example, you may ask Alpine County to send information to your work address instead of your home address. You may also specify how you wish us to contact you to provide appointment reminders. You must make such requests in writing. You do not need to explain the reason for your request. Right to File a Complaint. You have the right to file a complaint if you do not agree with how Alpine County has used or disclosed information about you. Right to Receive a Paper Copy of this Notice. You have the right to receive a paper copy of this notice or additional copies. How to Contact Alpine County to Review, Correct, or Limit Your Protected Health Information You may contact the Alpine County Mental Health Department, Health Department, or the Alpine County Paramedics, or the Alpine County Privacy Officer at the address listed at the end of this notice to: - Ask to look at or copy your records - Ask to limit how information about you is used or disclosed - Ask to cancel your authorization - Ask to correct or change your records - Ask for a list of the disclosures Alpine County has made of information about you. Alpine County may deny your request to look at, copy or change your records. If Alpine County denies your request, we will send you a letter that tells you why your request is being denied and how you can ask for a review of the denial. You will also receive information about how to file a complaint with Alpine County or with the U.S. Department of Health and Human Services, Office of Civil Rights. How to File a Complaint or Report a Problem You may contact the Alpine County Privacy Officer or the United States Department of Health and Human Services if you want to file a complaint or to report a problem with how Alpine County has used or disclosed information about you. The services you receive from Alpine County will not be affected by any complaints you make. Alpine County cannot retaliate against you for filing a complaint, cooperating in an investigation, or refusing to agree to something that you believe to be unlawful. To file a complaint with the County of Alpine, contact: To file a complaint with the Federal Government, contact:: Alpine County Privacy Officer U.S Department of Health and Human Services Beth Nunes, Alpine County Administration Office for Civil Rights P.O. Box 387, Markleeville, Ca. 96120 Room 509F, HHH Building Telephone number: [PHONE REDACTED] 200 Independence Avenue, S.W. Washington D.C., 20201 Telephone Number: [PHONE REDACTED] Changes to This Notice We reserve the right to revise or change the terms of this Notice, and to apply those changes to our policies and procedures regarding your medical/health information. You have the right to be notified of any changes to this Notice and to receive a copy of those changes in writing. To obtain a copy of this Notice once it has been changed, you can either ask your treatment provider or call or write the Alpine County Privacy Officer at the above address. Alpine County is required by law to maintain the privacy of PHI as described above and to provide individuals with notices of its legal duties and privacy practices with regard to PHI. Participant Keeps this Page