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

Who will follow this notice

This notice describes the privacy practices of the Facility in which you reside, that of all employees, staff and other Facility personnel and any member of a volunteer group or a student that we allow to help you while you are in the Facility.

Our pledge regarding your health information

We understand that information about you and your health is personal. We are committed to protecting your health information. We create a record of the care and services you receive at the Facility, as well as records regarding payment for those services. We need these records to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or maintained by the Facility, whether made by Facility personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by federal law to make sure that medical information that identifies you is kept private; to give you this notice of our legal duties and privacy practices with respect to medical information about you; and to follow the terms of the notice that is currently in effect. We will also follow the relevant privacy laws of the state in which the Facility is located when those laws are more stringent than federal privacy laws.

How we may use and disclose health information about you

We may use or disclose your health information in one of the following ways: (1) when permitted by law; (2) when required by law; (3) pursuant to your verbal agreement (for use in our Facility directory or to discuss your health with family or friends who are involved in your care); and/or (4) pursuant to your written authorization, when we are required to obtain it.

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

• For Treatment:

We may use health information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other Facility personnel who are involved in taking care of you at the Facility. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the Facility also may share medical information about you in order to coordinate your care.

• For Payment:

We may use and disclose health information about you so that the treatment and services you receive at the Facility may be billed, and that payment may be collected from you, an insurance company, or another third party. For example, we may include information about services that you received at the Facility on your monthly statement so that you can pay us for the services.

• For Health Care Operations:

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the Facility and to make sure that all residents receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Facility residents to decide what additional services the Facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Facility personnel for review and learning purposes.

• Treatment Alternatives:

We may use and disclose medical information to tell you about or recommend possible treatment options or alternative services that may be of interest to you.

• Business Associates:

There are some services provided in our organization through contracts with business associates. When these services are contracted, we may disclose your health information so that our business associates can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

• Appointment Reminders:

We may use and disclose medical information about you for the purpose of helping you remember your scheduled healthcare appointments.

• Facility Directory:

If you agree, we may include certain limited information about you in the Facility directory while you are a resident at the Facility. This information may include your name, location in the Facility, your general condition (e.g., fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends, and clergy can visit you in the Facility and generally know how you are doing.

• Name Placement:

We may place your name on the door to your room, on a meal tray, and on pieces of equipment that you might use, including a wheelchair. This aids our staff in identifying your items in order to provide you the best possible care. Further, this practice will assist you in locating your room and equipment. In order to foster a sense of community, we also like to post special events on our bulletin boards, such as your birthday or the birth of a grandchild. If you should choose not be included on these bulletin boards, please let us know.

• Verbal Agreement:

Pursuant to your verbal agreement, or if we feel that it is in your best interest, we may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort.

• As Required By Law:

We will disclose medical information about you when required to do so by federal, state, or local law.

• To Avert a Serious Threat to Health or Safety:

We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

• Private Sitters:

If you hire a private sitter, we will disclose medical information about you to aid your sitter in caring for you.

• Assistance During Special Events:

From time to time, we may schedule a special event, such as a field trip or a group activity or game. This special event may require the assistance of volunteers or staff members not normally involved in your care, who will need to know certain types of information about you. For example, a member of our maintenance team may serve bag lunches on a field trip and will need to know your dietary restrictions.

• Fundraising Activities:

We may use a limited amount of your health information for purposes of contacting you or your representative to raise money for our Facility and its operations.

Special Situations

• Organ and Tissue Donation:

If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

• Military and Veterans:

If you are a member of the armed forces, we may release medical information about you as required by military command authorities.

• Workers’ Compensation:

If applicable, we may release medical information about you for workers’ compensation or similar programs.

• Public Health Risks:

We may disclose medical information about you for public health activities. These activities generally include the prevention or control of disease, injury, or disability; reporting of abuse, deaths, or problems with medications or products; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

• Health Oversight Activities:

We may disclose medical information to a health oversight agency for activities authorized by law. These activities are necessary for the government to monitor the health care system, government programs, and compliance with the law.

• Lawsuits and Disputes:

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process served by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

• Law Enforcement:

We may release medical information if asked to do so by law enforcement officials. For example, we may release information in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; and to report a crime and provide information about crime victims.

• Coroners, Medical Examiners and Funeral Directors:

We may release medical information to a coroner or medical examiner. We may also release medical information about residents of the Facility to funeral directors as necessary to carry out their duties.

• National Security and Intelligence activities:

We may release medical information about you to authorized federal officials for national security activities authorized by law.

Other uses of medical information

Other uses and disclosures of medical information not covered by this notice or permitted/required by the laws that apply to us will be made only with your written authorization. For example, we would be required to seek your written authorization before providing certain health information to a pharmaceutical company for purposes of their marketing a product to you. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Organized healthcare arrangement

In our Facility, care and services are provided to you by our Facility staff as well as by other health care providers. Although these providers are all independent, they cooperate to provide an integrated system of care to you. This type of health care setting in which you receive care from more than one health care provider is called an organized health care arrangement (“OHCA”). We may share your health information with the providers in the OHCA for treatment, payment, and healthcare operations of the OHCA. For example, members of the OHCA may participate in committees that review the quality of services provided in the Facility. We participate in an OHCA with certain physicians, pharmacists, therapists, dieticians, social workers, and other health care providers. This notice of privacy practices describes how we use and disclose your health information; however, you will receive separate notices of privacy practices from each of the other participants in the OHCA, and each participant will separately address any questions or requests you might have with regard to your privacy.

Your rights regarding medical information about you

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy:

You have the right to inspect and copy your medical and billing information, and any other information that may be used to make decisions about your care. Usually, this includes your medical and billing records, but does not include psychotherapy notes.

• To inspect and copy your medical information, you must submit your request in writing to the Facility administrator. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
• We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed if the denial is made for certain reasons. Another licensed health care professional chosen by the Facility will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• Right to amend:

If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Facility. To request an amendment, your request must be made in writing and submitted to the Facility administrator. In addition, you must provide a reason that supports your request.

• We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the medical information kept by or for the Facility; (3) is not part of the information which you would be permitted to inspect and copy; or (4) is accurate and complete.
• Right to an Accounting of Disclosures:

You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Facility administrator. Your request must state a time period, which may not be longer than six years for oral or paper protected health information, nor longer than three years for electronic protected health information; and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• Right to Request Restrictions:

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations purposes. You may also request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

• To request restrictions, you must make your request in writing to the Facility administrator. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
• Right to Request Confidential Communication:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we send all bills to a certain address. To request confidential communications, you must make your request in writing to the Facility administrator. We will not ask you the reason for your request. We will accommodate all reasonable requests.

• Right to a Paper Copy of This Notice:

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice contact the Facility administrator.

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Changes to this notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Facility. The notice will contain the effective date on the first page, in the top right-hand corner.

Concerns

If you believe your privacy rights have been violated, you may file a concern with the Facility administrator. In addition, you may file a written concern with the Office of Civil Rights of the Department of Health and Human Services. You will not be penalized in any way for filing a concern.

If you have any questions about this notice, please contact the Facility administrator.