Are you protecting the privacy of the MDS Data?

As a facility submitting MDS data to CMS, you must abide by the Federal and State regulations with respect to maintaining resident data. The Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 version 1.13 states that “all contractual agreements, regardless of their type, involving the MDS data should not violate the requirements of participation in the Medicare and/or Medicaid program, the Privacy Act of 1974 or any applicable state laws.”

Effective 6-17-2013 the privacy act statement for health care records was implemented. This form provides to the Resident the advice required by the Privacy Act of 1974 and is NOT a consent form. This form does provide permission to release Health Care Information.
This form is found on Pages 1-16, 1- 17 and 1- 18 of the RAI manual at and should be included as a part of your admission packet.

NOTE: “providers may request to have the Resident or his or her Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required.”
All Residents and or their Representatives MUST be supplied with a copy of the notice. Including this form in your admission packet ensures you are in compliance with the Medicare Regulation outlined in Chapter 1.8, Protecting the Privacy of the MDS Data.