Advanced Directive Acknowledgement/HIPAA/Home Care Privacy Rights Acknowledgement

acknowledge that the Agency has provided me with information. which indicates that I may accept, or reject, any medical treatment, including any particular care specified:

• Living Will or Out of Hospitals Do not Resuscitate
• Statutory Power of Attorney for Health Care decisions
• Advance Directives in Pennsylvania - A Health Care Directive
• HIPAA/Home Care Privacy Rights

I also understand that it is my responsibility to ask question about the information, provided by the Agency. They have offered to provide a copy of the state's illustrative forms under state law if I request. I have also been advised to consult with my physician, lawyer, family, clergy, social worker, or other qualified personnel for additional information or contact with a lawyer, should I need assistance in changing the forms to reflect my treatment wishes or in executing a living will or statutory Power of Attorney for healthcare decisions.

I understand that this Agency will honor the advance directives and is willing and able to provide any procedure, specified on the advance directives.

I understand that the fact that I have, or have not, signed a living will or Statutory Power of Attorney for Home Care decisions does not affect the medical treatment and home care to be provided, by the Agency. I understand that it is the Agency's written policy to fully comply, through it's healthcare providers with the terms of a patient's Living Will or Statutory Power of Attorney for Healthcare decisions to fullest extent, permitted by state statutory Power of Attorney for Healthcare decisions to fullest extent permitted by state law.

I have been given an explanation, and acknowledge receipt of, the HIPAA PRIVACY RIGHTS. I understand that I may contact the Agency at any time for questions or concerns.

HIPAA PRIVACY RIGHTS
Patients have the right to give adequate notice concerning the use/disclosure of their PHI on the first date of service delivery, or as soon as possible after an emergency.

The Privacy Rule grants patients new rights over their PHI, including the following:
1. Receive a Privacy Notice at the time of the first delivery of service
2. Restrict use and disclosure, although the covered entity is not required to agree.
3. Have PHI communicated to them by alternate means and at alternate locations to protect confidentiality.
4. Inspect, correct and amend PHI and obtain copies, with some exceptions,
5. Request a history of non-routine disclosures for six years prior to the request, and
6. Contact designated persons regarding any privacy concerns or breach of privacy, within the facility of at HHS.