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(User Friendly Language Version)


902 Day Street

Shenandoah, Iowa 51601


This notice describes how private information about you may be used and shared and how you can look at the information. Nishna Productions, Inc. is required by law to provide you with this Notice so that you will understand how we may use or share your information from your Designated Record Set. The records NPI keeps may include financial and health information called “Protected Health Information” (PHI) or simply “health information.” We have to follow these rules. If you have any questions about this Notice, please contact our Privacy Officer at 712-246-1242 or 712-623-4362.


Understanding Your Health Record and Information

Each time NPI works with you, a record of our service is made containing health and financial information. This record contains information about how you are doing, the service we provide, and how we will get paid. We may use and/or share this information to:

  • Plan your services

  • Talk with other people involved in your services

  • Document the services you receive

  • Teach other people about your services

  • Provide information for medical research

  • Provide information to public health officials

  • Improve the services we provide

  • Get paid for the services we provide

Understanding what is in your record and how your health information is used helps you to:

  • Make sure it is right

  • Understand who may look at your health information

  • Make good decisions when deciding who to share your private information with.


How We May Use and Share Protected Health Information About You

The following lists tell the ways that we may use and share your private health information.

A. Uses and Disclosures for Treatment, Payment and Administrative Operations

1. For Treatment. We may use or share health information about you to provide you with services. We may share health information about you to doctors, nurses, therapists or health care people in order to get you the services you need.

2. For Payment. We may use or share your protected health information (PHI) so that we get paid for the services we have given to you.

3. For Administrative Operations. We may use and share PHI about you to make sure you are receiving good services and to make changes when things need to improve


Other Allowable Uses of Your Health Information

  • Business Associates/ Providers – There are times when people who do not work at NPI need to get information about you so you can get the services you need. If this happens we may share information with them.

  • Treatment Alternatives – We may use and share health information to tell you about services you might be interested in.

  • Health Related Benefits and Services and Reminders – We may contact you to remind you about appointments or give you information about other services you might be interested in.

  • Fundraising Activities – We may contact you and ask if we can use information about you in order to raise money for NPI. We will only share information, such as your name and what services you get. You do not have to let us share this information if you don’t want to. If you do not want NISHNA PRODUCTIONS, INC., or its foundation, to use your information for fundraising you must tell your Program Manager and they will tell the Privacy Officer at 712-246-1242 or 712-623-4362.

  • Individuals Involved in Your Services or Payment for Your Services – We may share information about you with the friends or family who are part of your services/life unless you don’t want us to. If there is a family member or friend that you do not want to get your information, please tell your Program Manager and they will tell the Privacy Officer at 712-246-1242 or 712-623-4362.

  • As Required By Law – We will share information about you when the law says we have to.

  • To Avert a Serious Threat to Health or Safety – We may use and share health information about you to stop a threat to your health and safety or the health and safety of the public or another person. We would do this only to help prevent the threat.

  • Organ and Tissue Donation – If you are an organ donor, we may share health information to organizations that handle organ donations and transplants.

  • Proof of Immunization – We may use or share immunization information with a school about you if you are a student or may become a student of the school and the school needs the information.

  • Victims of Abuse, Neglect or Domestic Violence – We may share PHI if we feel that you are being hurt in some way and need to get help from some other provider of services.

  • Military and Veterans – If you were in the military we might share information about you as required by the military in order to get you services.

  • Worker’s Compensation – We may share health information about you for worker’s compensation or other work related insurance.

  • Reporting – Federal and state laws may require or permit NPI to share certain health information related to the following:

Public Health Risks – We may share health information about you for public health purposes including:

  • Prevention or control of disease, injury or disability

  • Reporting births and deaths

  • Reporting child abuse or neglect

  • Reporting reactions to medications or problems with products

  • Notifying people of recalls of products

  • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease

  • Notifying the appropriate government authority if we believe an individual has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities – We may share health information to agencies that make sure we are doing our jobs. They may do inspections, investigations, or even look over our work.

Judicial and Administrative Proceedings – If you are involved in a lawsuit or some type of legal problem we may share your information if the court says we have to.

  • Law Enforcement – We may share health information when requested by the law:

  • In response to a court order, subpoena, warrant, summons or similar process;

  • To identify or locate a suspect, fugitive, material witness, or missing person;

  • About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;

  • About a death we believe may be the result of criminal conduct;

  • About criminal conduct at the Facility; and

  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

  • Coroners, Medical Examiners and Funeral Directors – We may share medical information to a coroner, medical examiner, or funeral director if you die, so they can do their job.

  • National Security and Intelligence Activities – We may share health information about you to the government if it is a matter of National Secuirty.

  • Correctional Institution – If you go to jail we may share information about you with the jail.


Other Uses of Health Information

We will not share information about you in other cases unless you give us permission by signing a consent form. If you or your guardian do not sign a consent form then we will not share information about you. You can take back your consent if you change your mind, by signing and dating the Revocation Section on the same consent form.


Your Rights Regarding Health Information About You

The information NPI keeps about you belongs to NPI but you can look at most of it if you want to. You have the following rights regarding your health information:

  1. Right to inspect and copy.

You can ask to look at or have copies of the information NPI has about you. If you want copies you may have to pay for them. We cannot let you look at or have copies of some things like information from other places and information protected by law. We may tell you that you can’t look at or have copies out of your file but you can ask for us to explain why or you can ask us to reconsider our decision. If the information you want came from some other provider we can tell you how to contact them to get the information. You can ask your Program Manager to help you get the information you want and they will contact the Privacy Officer to make sure it is okay. If you can’t get the information you want we will send you a letter telling you why. If the information you want is kept on the computer and you want it e-mailed you need to tell us.

B. Right to amend.

If you think that any information we have about you in our files is incorrect you can write to us and tell us why you think it is wrong and ask us to change it. If we can change it we will let you know and we will change it. If we cannot change it we will write to you and tell you why. We may also tell you we can’t change your information if the information:

  • was not created by us, unless the person or entity that created the health information is no longer available to make the amendment;

  • is not part of the health information we maintain to make decisions about your services;

  • is not part of the health information that you would be permitted to inspect or copy; or

  • is accurate and complete.

If we tell you we can’t change the information you can write a letter that says why you disagree with our information. You can also ask that your letter and our letter be attached to your information anytime we share it.

C. Right to an accounting of disclosures.

You have the right to ask for a list of the information we have shared about you. This list will not include some of the information we have shared, for example, when we share so we can provide you services, so we can get paid; when we share with you or when you have given is permission to share your information; etc. To ask for a list of the times we have shared your information, you must ask the Privacy Officer by writing a letter. The letter has to say the time period for which you want the information. This time period should not be longer than six years and not include dates before April 14, 2003. The first time, every year, you ask for copies they will be free after that you will have to pay for the copies and we will tell you how much they will cost.

If someone gets your information from NPI without permission we must tell you.

D. Right to request restrictions.

You have the right to say if you do not want some of your information shared with other people, your family, or friends. If we can’t provide your services without sharing the information we may tell you we can’t keep it private. If you want us to limit the information we share you have to talk to your Program Manager and they will help you write to the Privacy Officer and make a list of: (a) what information you want to limit; (b) whether you want to limit use or sharing; and (c) who we cannot share information with.

E. Right to request confidential communications.

You can decide when, where and how we talk to you about your services. We must make sure we keep your information private.

F. Right to a paper copy of this notice.

You have the right to a paper copy of the Notice of Privacy Practices. You may request a copy at any time by contacting your Program Manager or the Privacy Officer. A copy of the Notice of Privacy Practices is on our web site at


Changes to this Notice

We can change this policy at any time but if we do change it we will get you a new copy. We will post copies at the group homes, day services center, and both vocational training centers. If you want a new copy anytime you can contact your Program Manager and they will get one from the Privacy Officer.



If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. All complaints must be submitted in writing. Our Privacy Officer will assist you with writing your complaint, if you request such assistance. We will not retaliate against you for filing a complaint. To file a complaint with us, contact our Privacy Officer by telephone at 712-246-1242 or 712-623-4362 or by mail at 902 Day St., Shenandoah, Iowa 51601.


Notice of Privacy Practices User Friendly-Forms, Consumer

Implemented: 9-23-13





Acknowledgment of Receipt of Notice of Privacy Practices






This is to acknowledge my receipt of NISHNA PRODUCTIONS, INC.’s Notice of Privacy Practices (effective date March 1st, 2013) on the date stated below.






Date of Individual’s or Personal Representative’s Signature





Name of Personal Representative (If applicable)






Description of Representative’s

Authority to Act for the Individual (If applicable)



















Signature of Individual or

Personal Representative





Individual’s Name






Individual’s Address

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