DADS and Hope Horizon LLC, require that all employees must review and understand the following curriculum on a yearly basis and complete the competency test to follow.

What is HIPAA?

Health Insurance Portability and Accountability Act of 1996. The Privacy Rule under HIPAA requires health care providers to protect privacy of medical records and identifies certain rights of persons served to control use and disclosure of and access their medical records.

Who is affected?

All Healthcare organizations including healthcare providers, physician's offices, health plans, public health authorities, life insurers, clearinghouses, billing agencies, information system vendors, service organizations, and universities. HIPAA a1SQ indirectly affects business associates who have access to patient records. A Business Associate is any entity that performs services to, or on behalf of, a covered entity such as Hope horizon LLC, and uses or discloses protected health information that belongs to Hope Horizon LLC.

What is Protected Health Information (PHI)?

"Protected health information" is any information, whether oral or recorded in any form or medium that:
  • Is created or received by a health care provider (Hope Horizon LLC), health plan, public health authority, employer, life insurer, school or university, or healthcare clearinghouse; and
  • Relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual or the past, present or future payment for the provision of health care to that individual.

PHI includes any information - oral, recorded, written on paper, or sent electronically - about a person's physical or mental health, services rendered or payment for those services. The standards apply to all "information" not just the traditional medical record that we are familiar with.

This "information" includes any personal information connecting the patient to the records. This kind of personal information is called "Identifiable Health Information." The 19 items of information that might connect personal health information to the individual patient may include the individual's:

  • name
  • address (street name, city, county, zip code, equivalent geographic codes)
  • social security number
  • other identification numbers (health plan number, license number)
  • finger and voice prints
  • photo images
  • names of relatives
  • names of employers
  • date of birth
  • phone or fax numbers, e-mail addresses
  • medical record numbers, account numbers
  • physician's personal notes
  • billing information

Client Rights Under the HIPAA Privacy Rule:

  • Right to receive notice of privacy practices. A copy must be given to each client starting April 14, 2003. We must also ask the client to sign an Acknowledgment Receipt for Notice of Privacy and place the signed acknowledgment in the client record.
  • Right to request restrictions. The client can ask us to limit some of the ways we use or share their health information. We will consider their request, but the law does not require us to agree to it. If we do agree, we will put the agreement in writing and follow it, except in case of emergency. We cannot agree to limit the uses or sharing of information that are required by law.
  • Right to request confidential communications. The client can ask us to contact them at a different place or in some other way. We will agree to their request as long as it is reasonable.
  • Right to access Protected Health Information (PHI). The client can look at or get a copy of the health information that we have about them. There are some reasons why we will not let them see or get a copy of their health information, and if we deny their request we will tell them why. The client can appeal our decision in some situations. They can choose to get a summary of their health information instead of a copy. The client will be charged a reasonable fee for the summary or copy of their health information.
  • Right to request amendments. The client can ask us to correct information in their records if they think the information is wrong. We will not destroy or change our records, but we will add the correct information to their records and make a note in their records that they have provided the information.
  • Right to request accounting. The client can get a list of when we have given health information about them to other people in the last six years. The list will not include disclosures for treatment, payment, health care operations, national security, law enforcement, or disclosures where they gave their permission. The list will not include disclosures made before April 14, 2003. There will be no charge for one list per year.
  • Right to file a complaint. If the client believes their privacy rights have been violated, they can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Hope Horizon LLC Responsibilities:

  • To maintain the privacy of the clients health information.
  • Provide clients with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about them.
  • Abide by the terms of the privacy notice.
  • Notify clients if we are unable to agree to a requested restriction.
  • Accommodate reasonable requests they may have to communicate health information by alternative means or at alternative locations.
  • Penalties for privacy rights violations:

    • Non-Compliance: $100 for each violation, up to $25,000 maximum per year (applies to all HIPAA requirements).
    • Wrongful Disclosure: Up to $50,000 & imprisoned up to 1 yr for each offense.
    • If disclosed under false pretenses: Up to $100,000 & imprisoned up to 5 yrs.
    • If disclosed with intent to sell information or reap other personal gain: Up to $250,000 & imprisoned up to 10yrs.


If you have any questions regarding areas of privacy, contact Luke Kelly Office Administrator (972) 234-9001 to file a privacy violation complaint. Luke Kelly: (972) 234-9001 or his cell phone (214) 557-4514

You may also file a complaint with: U.S. Department of Health and Human Services: (800) 368-1019 (toll free).