Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

Protection of Protected Health Information (PHI)

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Village Shalom is required by law to maintain the privacy of health information that identifies you (protected health information or PHI) and to provide you with notice of our legal duties and privacy practices regarding PHI. Village Shalom is committed to the protection of your PHI and will make reasonable efforts to ensure the confidentiality of your PHI, as required by statute and regulation. We take this commitment seriously and will work with you to comply with your right to receive certain information under HIPAA.

Standard Use and Disclosure of Your Medical Information

Village Shalom uses your medical information to provide you with medical treatment and services, to receive payment for those services, and in daily health care operations.

Treatment: Village Shalom may disclose your medical information to those involved in your treatment on an as-needed basis. For example, we may disclose information to your doctor to assist them in making a determination on a course of treatment for you.

Payment: Village Shalom may be required to use or disclose your medical information in order to obtain payment for services we render. For example, when Village Shalom submits bills to an insurance company, Medicare, or another health care agency, they require a listing of the services you received from Village Shalom in order for Village Shalom to receive payment for those services.

Health Care Operations: Village Shalom may also use and disclose your medical information in our everyday health care operations. For example, your medical information may be used to assist us in evaluating the performance of this organization through internal and external performance/quality audits.

Business Associates: Village Shalom may disclose PHI to its business associates to perform certain business functions or provide certain business services to Village Shalom. For example, we may use another company to perform billing services on our behalf. All of our business associates are required to maintain the privacy and confidentiality of your PHI. In addition, at the request of your health care providers or health plan, Village Shalom may disclose PHI to their business associates for purposes of performing certain business functions or health care services on their behalf. For example, we may disclose PHI to a business associate of Medicare for purposes of medical necessity review and audit.

Uses and Disclosures That Require Your Consent

Your consent is required for the following uses and disclosures and will be made only with written authorization from you:

  • If you have paid for services out-of-pocket, in full, you have the right to request with written authorization that Village Shalom not disclose PHI related solely to those services to a health plan. Village Shalom must accommodate your request, except where Village Shalom is required by law to make a disclosure.
  • Uses and disclosures of psychotherapy notes
  • The use and disclosure of PHI for marketing purposes, including subsidized treatment communications
  • Disclosures that constitute a sale of PHI
  • Other uses and disclosures not described in this Notice of Privacy Practices
  • If Village Shalom sends fundraising communications to you, you have the right to opt out of such fundraising communications with each solicitation.

To send your written authorization to Village Shalom, refer to the Contacting Village Shalom section at the end of this notice.

You may revoke any such authorization at any time in writing, unless (1) Village Shalom has already taken action in reliance upon the authorization you have provided; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and other law(s) provide the insurer the right to contest a claim under the policy.

Uses and Disclosures That Do Not Require Your Consent in addition to the general uses and disclosures of your information noted above, there may be some more specific situations when it is necessary, and permissible, for Village Shalom to use or disclose of your medical information as follows:

  • Public health authorities in order to prevent or control disease, to report birth or death, and for the purpose of public health investigations, interventions and other related matters
  • Government authorities, as required by law, of a person who may be a victim of abuse, neglect or domestic violence
  • Agencies that oversee insurance health benefit programs for the purpose of audits, investigations, inspections or other activities
  • A court order or subpoena in a judicial or administrative proceeding
  • Law enforcement officials for a law enforcement purpose in the following situations: when required by law, for identification and location purposes, if you are suspected to be a victim of a crime, to report suspicion of death by criminal conduct, to report suspicion of criminal conduct occurring on the grounds of our facility and in the case of an emergency
  • A coroner, medical examiner or funeral director in the event of your death
  • Organ donation organizations if the insured has previously made those arrangements
  • Limited health information may be disclosed if necessary to prevent an immediate threat to the health or safety of the public.
  • Special government circumstances involving: military or veterans activities, national security and intelligence activities, protective services for the President, medical suitability determinations, law enforcement custodial situations and government programs providing public benefits
  • The Food & Drug Administration (FDA) or the Center for Disease Control (CDC) for reporting adverse events with respect to immunizations and or health screening tests
  • Employers of Food Handlers (Hepatitis A Ordinance NO. 19,770,199) for proof of Hepatitis A vaccinations as required by the County Council of St. Louis County, Missouri

All other uses or disclosures of your medical information will be made only with your written authorization. You may revoke your written authorization at any time.

Our Duties

  • Village Shalom’s policy regarding your medical record is that Village Shalom must maintain the privacy of your medical information and must follow the provisions in this notice.
  • Village Shalom has the right to change the provisions of this notice, and any changes may be effective for any current health information about you and any information that may be obtained in the future. Any changes to this notice will be effective for all health information that we maintain about you.

Your Rights

The following is a description of your rights with respect to your protected health information.

  • Right to Request a Restriction The HIPAA Privacy Rule provides that you may request a restriction on the PHI Village Shalom uses or discloses about you for payment, treatment or health care operations. It also provides that you have a right to request a limit on disclosures of your PHI to family members or friends who are involved in your care or the payment for your care. Village Shalom may disclose information about you that is directly relevant to any member of your family, or to a designated caregiver of yours, if that person is involved with your care or the payment for your care. Village Shalom may also use or disclose your health information to notify, identify or locate a family member (or other person responsible for your care), of your location, condition or death. You may restrict such use or disclosure by contacting Village Shalom in the Contact Village Shalom section of this notice.
  • Right to Request Confidential Communications You may request to receive your PHI by alternative means or at an alternative location if you reasonably believe that other disclosure could pose a danger to you. For example, you may only want to have PHI sent by mail or to an address other than your home. While we are not required to agree to all requests, Village Shalom will accommodate all reasonable requests for confidential communications. For more information about exercising these rights, contact Village Shalom using the contact information at the end of this Notice.
  • Right to Request Access You have the right to inspect and have a copy of your protected health information. You must submit your request in writing. Contact Village Shalom using the contact information at the end of this Notice.
  • Right to Request an Amendment You have the right to request an amendment of your protected health information held by Village Shalom if you believe that information is incorrect or incomplete. If you request an amendment of your protected health information, your request must be submitted in writing to the Privacy Officer in the contact information at the end of this Notice and must set forth a reason(s) in support of the proposed amendment. In certain cases, Village Shalom may deny your request for an amendment. For example, Village Shalom may deny your request if the information you want to amend is accurate and complete or was not created by Village Shalom. If Village Shalom denies your request, you have the right to file a statement of disagreement. Your statement of disagreement will be linked with the disputed information and all future disclosures of the disputed information will include your statement.
  • Right to Request an Accounting You have the right to request an accounting of certain disclosures Village Shalom has made of your protected health information. You may request an accounting using the contact information at the end of this Notice. You can request an accounting of disclosures made up to six years prior to the date of your request, except that the Plan is not required to account for disclosures made prior to April 14, 2003.
  • Right to be Notified of a Breach You have the right to be notified in the event that Village Shalom (or a Business Associate of Village Shalom) discovers a breach of unsecured protected health information, unless there is a demonstration based on a risk assessment that there is a low probability the PHI has been compromised. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what can be done to mitigate any harm.
  • Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice, even if you have agreed to accept this Notice electronically. To obtain such a copy, please contact Village Shalom using the contact information at the end of this Notice.


If you believe that that your privacy rights have been violated, you may file written complaint to the Village Shalom Privacy Officer or to the Secretary of the Department of Health and Human Services. You are protected from retaliation for any complaints you make. To file your complaint with Village Shalom, refer to the Contacting Village Shalom section at the end of this notice.


I will sign an Acknowledgement as attached to this Notice of Privacy Practices, which states that I have been provided with a copy of the Village Shalom’s Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact Village Shalom in the Contacting Village Shalom section below. I also understand that I am entitled to receive updates upon request if Village Shalom amends or changes its Notice of Privacy Practices in a material way.

Contacting Village Shalom

You may exercise the rights described in this notice by contacting the Village Shalom Privacy Officer.

HIPAA Privacy Officer
5500 West 123rd Street
Overland Park, KS 66209

Effective: April 1, 2003
Updated: December, 2006
Updated: September, 2013