This statement gives you advice required by law (The Privacy Act of 1974). This statement is not a consent. It will not be used to release or to use your health care information.

1. Authority for collection of your information, including your social security number and whether or not you are required to provide information for this assessment. Sections 1102(a), 1154, 1862 (o), 1861(z), 1864, 1865, 1866, 1871, 1891(b) of the Social Security Act. Medicare and Medicaid participated home health agencies must do a complete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the Outcome and Assessment Information Set (OASIS) when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Center for Medicare/Medicaid Services (CMS) to be sure that the home health agency meets quality standards and gives appropriate healthcare to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the federal Privacy Act of 1973 and the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System of Records. You have the right to see, copy, review and request correction of your information in the HHA OASIS System of Records.
2. Principal Purposes For Which Your Information Is Intended To Be Used.

The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-70-9002. Your health care information in the HHA OASIS System of Records will be used for the following purposes:

• Support litigation involving the Centers for Medicare & Medicaid Services;
• Support regulatory, reimbursement, and policy functions performed within the Centers for Medicare & Medicaid Services or by a contractor or consultant;
• Study the effectiveness and quality of care provided by those home health agencies;
• Survey and certification of Medicare and Medicaid home health agencies;
• Provide for development, validation, and refinement of a Medicare prospective payment system;
• Enable regulators to provide home health agencies with data for their internal quality improvement activities;
• Support research, evaluation, or epidemiological projects related to the prevention of disease of disability, or the restoration or maintenance of health, and for health care payment related projects; and
• Support constituent requests made to a Congressional representative.

1. Routine Uses

These “routine uses” specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the HHA OASIS System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of the information may be to:

1. The federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services;
2. Contractors or consultants working for the Centers for Medicare & Medicaid Services to assist in the performance of a service related to this system of records and who need to access these records to perform the activity;
3. An agency of a State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of health care services provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of Federal/State home health agency programs within the State;
4. Another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services health insurance operations (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs;
5. Quality Improvement Organizations, to perform Title XI or Title SVII functions related to assessing and improving home health agency quality of care;
6. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment related projects;
7. A congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained.
8. Effect on You, If You Do Not Provide Information

The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services.

NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your representative to sign this statement to document that this statement was given to you. Your signature is NOT required. If you or your representative signs the statement, the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement.

Contact Information

If you want to ask the CMS to see, review, copy, or correct your personal health information that the Federal agency maintains in its HHA OASIS System of Records:

If you want to ask the CMS to see, review, copy, or correct your personal health information that the Federal agency maintains in its HHA OASIS System of Records:

Call 1-800-MEDICARE, toll free, for assistance in contacting the HHA OASIS System Manager. TTY for the hearing and speech impaired: 1-877-486-2048.