HIPPA-Form
Grievance Procedure Acknowledgement
I have read or have been advised of Unique Care Community Service’s Policy regarding Grievance Procedures and understanding that this information will be available to me at any guardian (s) or through correspondent, express without fear or reprisal, grievances, concerns and suggestions to; ➢ The Unique Care Community Services, Inc. Executive officers, ➢ The respective Developmental Disabilities (Local DDRO’s) Children Waiver Program ➢ The Commission on Quality of Care for Mentally Disable, or ➢ The Commissioner of OPWDD or Children Waiver . I have received a copy of the agency’s Grievance Procedure Policy.
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Acknowledgement Of Rights
ACKNOWLEDGEMENT OF RIGHTS
I HAVE READ OR HAVE BEEN ADVISED OF Unique Care Community Services’ policy regarding individual rights and rights pertaining to Habilitative Services and Medical Treatment. I understand that this information will be available to me at any time. . I have received a copy of the individual rights and the agency’s policy about protecting those rights.
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Liability Notice
I have received and read a copy of the Liability Notice from Unique Care Community Services,Inc:
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HIPPA Privacy
Dear Individual: Attached is a notice that tells you know Unique Care Community Services, Inc. Uses your clinical information, and protects your privacy. . New federal regulations require us to send this notice to everyone who gets services fromUnique Care Community Services, Inc. These regulations are known as the HIPAA Privacy rule.HIPAA is short for the federal Health Insurance Portability and Accountability Act of 1996. . The HIPAA Privacy rule DOES NOT CHANGE the way you get services from UCCS. It does not change the privacy rights that you have always had under State Mental Hygiene law. The Privacy rule requires UCCS to take some additional steps to make sure you are aware of your privacy rights. UCCS is not the only organization that must give people a privacy notice. Some others who must give Privacy notices include: . • Medicaid, Medicare, doctors, hospitals, drug stores (pharmacies) and other persons or organizations who give health care services. You can expect to receive a Privacy notice from everyone who provides or pays for your healthcare. , Please take time to read the UCCS Privacy notice. It has two parts. Frist there is a short notice that gives a summary of UCCS Privacy protections. Next, there is a longer notice with more details about how UCCS uses and discloses your clinical information. The notices tell you who you call or write for more information about the privacy of your clinical information in UCCS. We hope this information helps you to better understand your privacy rights regarding your clinical information. . Sincerely, Executive Director Unique Care Community Services, Inc. 1360 East 86th Street Brooklyn, NY 11236
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HIPPA Privacy Acknowledgement
HIPAA PRIVACY NOTICE ACKNOWLEDGEMENT
The HIPAA Privacy rule DOES NOT CHANGE the way you get services from Unique Care Community Services, Inc (UCCS). It does not change the privacy rights that you have always had under New York State Mental Hygiene law. The HIPAA Privacy rule requires U.C.C.S.to take some additional steps to make sure you are aware of your privacy rights. . . By signing this acknowledgement from I am confirming that:➢ I have received a copy of Unique Care Community Services, Inc. Privacy Notice➢ I understand that I can contact the people listed in the Privacy Notice to get moreinformation about my privacy rights at Unique Care Community Services, Inc
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