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.

I. Our Duty to Safeguard Your Protected Health Information

We are committed to preserving the privacy and confidentiality of your health information, whether created, received, transmitted by us, or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your health information, including electronic health information. Copies of our privacy policies and procedures are maintained in the business office. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revisions that we may make as necessary or authorized by law.

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care treatment or services you receive is considered Protected Health Information (PHI). As such, we are required to provide you with this Privacy Notice, which contains information regarding our privacy practices, explaining how, when, and why we may use or disclose your PHI, and your rights and our obligations regarding such uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure. We are also required by law to notify all affected individuals in case of a breach of unsecured PHI.

We reserve the right to change this notice at any time and to make the revised or changed notice effective for health information we already have about you, as well as any information we receive about you in the future. Should we revise or change this Privacy Notice, we will post a copy of the new or revised Privacy Notice in the main lobby and/or on our website, if applicable. You may also request and obtain a copy of the new or revised Privacy Notice from the business office.

Should you have questions concerning our Privacy Notices, the names, addresses, telephone numbers, etc., of the contacts are available through the business office and are listed on the last page of this document.

II. How We May Use and Disclose Your Protected Health Information

We use and disclose PHI for a variety of reasons. We have a limited right to use and disclose your health information for purposes of treatment, payment, or the operations of our organization. For other uses, you must provide written authorization unless the law permits or requires us to disclose information without your authorization.

Should it become necessary to release your PHI to an outside party or business associate, we will require the party or business associate to have a signed agreement with us, ensuring they extend the same degree of privacy protection to your information as we do. Privacy laws permit us to make some uses or disclosures of your PHI without your consent or authorization.

The following describes how we may use or disclose your PHI, including examples of each type of use or disclosure:

  • Uses and Disclosures Related to Treatment Alternatives, Health-Related Benefits, and Services
    We may use or disclose your PHI to inform you about treatment alternatives or health-related benefits and services. For example, we may notify you of newly released medications or treatments related to your condition.
  • Uses and Disclosures Related to Treatment
    We may disclose your PHI to those involved in providing medical and nursing care services and treatments to you. For example, we may release health information to nurses, nursing assistants, medication aides/technicians, medical and nursing students, therapists, pharmacists, medical records personnel, consultants, and physicians. We may also disclose your PHI to outside entities performing services related to your treatment, such as diagnostic laboratories, home health or hospice agencies, and family members.
  • Uses and Disclosures Related to Payment
    We may use or disclose your PHI to bill and collect payment for services or treatments we provided to you. For example, we may contact your insurance provider, health plan, or another third party to obtain payment.
  • Uses and Disclosures Related to Health Care Operations
    We may use or disclose your PHI for functions necessary to ensure you and others receive quality care and services. For example, we may take your photograph for medication identification purposes or use your health information to evaluate the effectiveness of the care and services you receive. Your PHI may also be shared with staff for auditing, care planning, treatment, and learning purposes. Additionally, we may combine your health information with data from other providers to study performance and improve care. Identifiable information will be removed for research purposes.
  • Uses and Disclosures Related to Fundraising Activities
    We may use limited PHI when raising funds for our organization. We may disclose your name, address, telephone number, and treatment dates to a related foundation for fundraising purposes. You may opt out of such communications by submitting a Request to Restrict the Use and Disclosure of Protected Health Information form, available in the business office.

III. Uses and Disclosures Requiring Your Written Authorization

For uses and disclosures of your protected health information beyond treatment, payment, and operations purposes, we are required to have your written authorization, except as permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information, except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. The name, address, and telephone number of the person to contact is located on the last page of this document. You may use our Authorization for Use or Disclosure of Protected Health Information form and/or our Revocation of an Authorization form to submit your request to us. Copies of these forms are available in the business office.

Uses or disclosures that require your written authorization include, but are not limited to, the following:

  1. Psychotherapy Notes:
    We are required to have your written authorization for the use or disclosure of your psychotherapy notes (if applicable), except to carry out treatment, obtain payment, or perform health care operations; or for a use or disclosure that is permitted or required by law.
  2. Marketing:
    We are required to have your written authorization for the use of your protected health information for marketing purposes, except if communication is in the form of face-to-face communication between you and our facility, or if you are provided a promotional gift of nominal value by our facility. If the marketing purposes for which we obtain written authorization involve financial compensation to us from a third party, this information will be stated in your authorization.
  3. Sale of Protected Health Information:
    We are required to obtain your written authorization for the sale of your protected health information. If the sale of your protected health information results in financial compensation to this organization, this information will be stated in your authorization.
  4. Other Uses and Disclosures Not Described in this Notice:
    We are required to obtain your written authorization for any uses or disclosures of your protected health information other than those described in this notice.

IV. Uses or Disclosures of Information Based Upon Your Verbal Agreement

In the following situations, we may disclose a limited amount of your protected health information if we provide you with advance oral or written notice and you do not object to such release or if such release is not otherwise prohibited by law.

However, if there is an emergency situation and you are unable to object (because you were not present or you were incapacitated, etc.), disclosure may be made if it is consistent with any prior expressed wishes and determined to be in your best interest. When a disclosure is made based on these or emergency situations, we will only disclose health information relevant to the person’s involvement in your care.

For example, if you are sent to the emergency room, we may inform the person that you suffered an apparent heart attack or stroke and/or provide information on your prognosis or progress. You will be informed and given an opportunity to object to further disclosures as soon as you are able to do so.

  1. Information Used or Disclosed in the Facility/Community Directory:
    (Only applicable for nursing and assisted living facilities.)
    We may use or disclose your name, unit or room number, and religious affiliation in our facility/community directory. We may also disclose your religious affiliation to a member of the clergy. Information concerning your general condition or room location may be provided to callers or visitors when they ask for you by name. You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection, or your objection may be made orally. The name, address, and telephone number of the person to whom you may make your objection are listed on the last page of this document.
  2. Information Disclosed to Family Members, Friends, or Others Involved in Your Care:
    We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. In the case of your death, we may disclose to a family member, friend, or others involved in your care, protected health information that is relevant to such a person’s involvement, unless doing so is inconsistent with any prior expressed preferences. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your family and/or friends about your general condition, location, and/or status (i.e., alive or deceased). You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection, or your objection may be made orally. The name, address, and telephone number of the person to whom you may make your objection is listed on the last page of this document.

V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization

State and federal laws and regulations either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorization include the following:

  1. When Required by Law:
    We may disclose your protected health information when a federal, state, or local law requires us to report information about suspected abuse, neglect, or domestic violence; report adverse reactions to medications or injury from a health care product; or respond to a court order or subpoena.
  2. For Public Health Activities to Prevent or Control Disease, Injury, or Disability:
    We may disclose your protected health information when required to collect information about diseases or injuries (e.g., your exposure to a disease or your risk for spreading or contracting a communicable disease or condition, product recalls, or to report vital statistics such as births or deaths to a public health authority).
  3. For Health Oversight Activities:
    We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, the state agency responsible for inspecting our organization, or other agencies responsible for monitoring the health care system. This may include reporting or investigating unusual incidents or ensuring compliance with applicable laws and regulations.
  4. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations, or Tissue Banks:
    We may disclose your protected health information to a coroner or medical examiner to identify a deceased individual or determine the cause of death. Health information may also be disclosed to a funeral director to carry out your wishes and perform necessary duties. If you are an organ donor, we may disclose your protected health information to the organization handling your organ, eye, or tissue donation for purposes of facilitating donation or transplantation.
  5. For Research Purposes:
    We may disclose your protected health information for research purposes only when a privacy board has approved the research project. Preparatory activities for approved research projects must be conducted onsite, and researchers will be required to sign a Confidentiality and Non-Disclosure Agreement before accessing health information.
  6. To Avert a Serious Threat to Health or Safety:
    We may disclose your protected health information to prevent a serious threat to your health or safety or the health or safety of others. Information will only be disclosed to those with the ability or authority to prevent or lessen the threat of harm.
  7. For Specific Government Functions:
    We may disclose protected health information of military personnel and veterans when requested by military command authorities, to authorized federal authorities for purposes of intelligence, counterintelligence, or national security activities, or to correctional institutions.

VI. Your Rights Regarding Your Protected Health Information

You have the following rights concerning the use or disclosure of your protected health information that we create or that we may maintain on our premises:

  1. Your Right to Request Restrictions on Uses and Disclosures of Your Protected Health Information:
    You have the right to request that we limit how we use or disclose your protected health information for treatment, payment, or health care operations. For example:
    • You have the right to request a restriction on certain disclosures to your health plan if the disclosure is purely for carrying out payment or healthcare operations, and the restriction you are requesting is for services paid for by you out-of-pocket.
    • You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care or services. For example, you could request that we not disclose to family members or friends information about a medical treatment you received.
    Should you wish a restriction placed on the use and disclosure of your protected health information, you must submit such request in writing. You may submit such request using our Request to Restrict the Use and Disclosure of Protected Health Information form. Copies of this form are available in the business office. The name, address, and telephone number of the person to whom the request is to be submitted is listed on the last page of this document. We are not required to agree to your restriction request. However, should we agree, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you.
  2. Your Right to Inspect and Copy Your Medical and Billing Records:
    You have the right to inspect and copy your health information, such as your medical and billing records that we use to make decisions about your care and services. In order to inspect and/or copy your health information, you must submit a written request to us. If you request a copy of your medical information, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filling your requests. We will provide you with information concerning the cost of copying your health information prior to performing such service. The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for Inspection/Copy of Protected Health Information form. Copies of these forms are available in the business office. We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your health information, we will provide you with written notice of our reasons for the denial and your rights for requesting a review of our denial. If such review is granted or is required by law, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons for denial. We will abide by the reviewer’s decision concerning your inspection/copy requests. You may submit your denial review requests on our Denial of Inspection/Copy of Protected Health Information form. Copies of these forms are available in the business office.
  3. Your Right to Amend or Correct Your Health Information:
    You have the right to request that your health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request. If we approve your request, we will make such amendments/corrections and notify those with a need to know of such amendments/corrections. We may deny your request if:
    • Your request is not submitted in writing.
    • Your written request does not contain a reason to support your request.
    • The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
    • It is not a part of the health information kept by or for our organization.
    • It is not part of the information which you would be permitted to inspect and copy.
    • The information is already accurate and complete.
    If your request is denied, we will provide you with a written notification of the reason(s) for such denial and your rights to have the request, the denial, and any written response you may have relative to the information and denial process appended to your health information. The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your amendment/correction requests on our Request for Amendment/Correction of Protected Health Information form. Copies of these forms are available in the business office.
  4. Your Right to Request Confidential Communications:
    You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we not send any health information about you to a family member’s address. We will agree to your request as long as it is reasonably easy for us to do so. To request confidential communications, you must:
    • Notify us in writing.
    • Indicate what information you wish to limit.
    • Indicate whether or not you wish to limit or restrict our use or disclosure of such information.
    • Identify to whom the restrictions apply (e.g., which family member(s), agency, etc.).
    The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for Restriction of Confidential Communications form. Copies of these forms are available in the business office.
  5. Your Right to Request an Accounting of Disclosures of Protected Health Information:
    You have the right to request that we provide you with a listing of when, to whom, for what purpose, and what content of your protected health information we have released over a specified period of time. This accounting will not include any information we have made for the purposes of treatment, payment, or health care operations or information released to you, your family, or the facility/community directory, disclosures made for national security purposes, or any releases pursuant to your authorization. Your request must be submitted to us in writing and must indicate the time period for which you wish the information (e.g., May 1, 2003, through August 31, 2005). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information. We will respond to your request within sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be notified of such extension. However, in no case will such extension exceed thirty (30) days. The first accounting you request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the twelve (12) month period. 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. The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for an Accounting of Disclosures of Protected Health Information form. Copies of these forms are available in the business office.
  6. Your Right to Receive a Paper Copy of This Notice:
    You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic copy of this notice. You may request a paper copy of this notice at any time or you may obtain a copy of this information from our website (as applicable). The name, address, and telephone number of the person to whom you may obtain a paper copy of this notice is listed below.

VII. How to File a Complaint About Our Privacy Practices

If you have reason to believe that we have violated your privacy rights, violated our privacy policies and procedures, or you disagree with a decision we made concerning access to your protected health information, etc., you have the right to file a complaint with us or the Secretary of the Department of Health and Human Services. Complaints may be filed without fear of retaliation in any form.

The name, address, and telephone number of the person to whom you may file your complaint is listed below. You may submit your complaint on our Privacy Practices Complaint form. Copies of these forms are available in the business office.

PROVIDER / PRIVACY CONTACT INFORMATION:

Provider Name
Address
Telephone Number
Fax Number

YOU MAY ALSO FILE COMPLAINTS WITH:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
(202) 619-0257
Toll-Free 1-877-696-6775