We respect the privacy of your protected health information (“PHI”) and are committed to maintaining such information in a confidential manner. This Notice of Privacy Practices (“Notice”) applies to all information and records related to your care that our facility receives or creates. It extends to information received or created by our employees, staff, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your PHI. It also describes your rights and our obligations regarding your PHI.


We are required by law to:

·      maintain the privacy of your PHI;

·      provide to you this detailed Notice of our legal duties and privacy practices relating to your PHI; and

·      abide by the terms of this Notice that are currently in effect.


For purposes of the HIPAA Privacy Rules, our facility is considered an affiliated covered entity and is covered by a HIPAA compliance plan



We may use and disclose your PHI for purposes of treatment, payment and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures that we may make in each of these categories.

A.   For Treatment. We will use and disclose your PHI in providing you with treatment and services. We may disclose your PHI to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, and physical therapists. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose PHI to individuals who will be involved in your care after you leave the facility.

B.    For Payment. We may use and disclose your PHI so that we can bill and receive payment for treatment and services you receive at the facility. For billing and payment purposes, we may disclose your PHI to your representative, an insurance or managed care company, Medicare, or another third party payer. For example, we may contact Medicare or your health plan to confirm your coverage or to request coverage information for a proposed treatment or service. 

C.    For Health Care Operations. We may use and disclose your PHI for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use PHI to evaluate our facility’s services, including the performance of our staff or to determine the most effective and efficient manner of providing services to our residents. 


We may also provide certain services by contracting with third parties, referred to as Business Associates.  In some cases, we will need to disclose your PHI to a Business Associate in order for them to provide the appropriate services to you and/or the facility.  We will only disclose your PHI to a Business Associate after we have received adequate contractual assurances from them that they will safeguard and keep confidential your PHI.




In some circumstances, we may disclose a limited amount of your PHI if we provide you with notice of our practices, and the opportunity to object to such release.  In an emergency situation, where you are unable to object, we may disclose your PHI provided such disclosure is consistent with any prior expressed intentions and deemed by us to be in your best interest.  When you are able to respond, you will be given an opportunity to object to further uses or disclosures.


A.   Facility Directory and Newsletter. Unless you object, we will include certain limited information about you in our facility directory and newsletter. This information may include your name, your location in the facility, your general condition and your religious affiliation.  Your religious affiliation may be given to a member of the clergy even if they do not ask for you by name.  The facility directory information may be released to people who ask for you by name.  Your name may appear in the facility newsletter related to special activities, such as your birthday.



Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your PHI to a family member or close personal friend, including clergy, who is involved in your care.  We may also disclose your PHI to a disaster relief organization for the purposes of notifying your family or friends about your general condition, location or status.


C. Uses and Disclosures Related to Treatment Alternatives, Reminders and Other Health Related Benefits.  We may use or disclose PHI to remind you about appointments.  We may also use or disclose PHI to inform you about treatment alternatives that may be of interest to you or to inform you about health-related benefits and services that may be of interest to you.


III.       WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES  (without obtaining your additional consent or authorization)

A.   As Required By Law. We will disclose your PHI when required by federal, state or local law to do so.

B.    Public Health Activities. We may disclose your PHI for public health activities. These activities may include, for example:

·      reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting abuse or neglect;

·      reporting to the federal Food and Drug Administration (FDA) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;

·      to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition or

·      for certain purposes involving workplace illness or injuries.


C.    Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your PHI to notify a government authority if required or authorized by law, or if you agree to the report.


D.   Health Oversight Activities. We may disclose your PHI to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.

E.    Judicial and Administrative Proceedings. We may disclose your PHI in response to  a court or administrative law. We also may disclose information in response to a subpoena, discovery request, or other lawful process.

F.    Law Enforcement. We may disclose your PHI for certain law enforcement purposes,     including:

·      as required by law to comply with reporting requirements;

·      to comply with a court order, warrant, subpoena, summons, or similar legal process;

·      to identify or locate a suspect, fugitive, material witness, or missing person;

·      when information is requested about the victim of a crime if the individual agrees or under other limited circumstances;

·      to report information about a suspicious death;

·      to provide information about criminal conduct occurring at the facility;

·      to report information in emergency circumstances about a crime; or

·      where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.


G.   Research.  We may disclose PHI of residents from our facility who choose to participate in research studies. Your PHI may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board of Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.


Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your PHI to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

I.      To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.

J.     Military and Veterans. If you are a member or former member of the armed forces, we may use and disclose your PHI as required by military command authorities. We may also use and disclose PHI when requested by appropriate federal authorities for the purposes of intelligence and other natural security activities, or to correctional facilities.

K.   Worker’s Compensation. We may use or disclose your PHI to comply with laws relating to workers’ compensation or similar programs.


L.     Fundraising.  We may use your PHI to contact you regarding our fundraising activities.  We may disclose this information to a business associate or foundation to assist with our fundraising.  If you do not want us to use information for fundraising purposes, you may notify us using the information listed at the end of this Notice.




We will use and disclose PHI (other than as described in this Notice or required by law) only with your written Authorization. You may revoke your Authorization to use or disclose PHI in writing, at any time. If you revoke your Authorization, we will no longer use or disclose your PHI for the purposes covered by the Authorization, except where we have already relied on the Authorization.




You have the following rights regarding your protected health information at the facility:

A.    You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of your PHI, including both medical and billing information for as long as we maintain the PHI.  In order to inspect and/or copy your PHI you must submit a written request to us.  We may charge you a reasonable fee for the cost of such copies.  You also have the right to request an electronic copy of you PHI.  If your PHI is not readily producible in such an electronic form or format, we will provide your PHI in a readable electronic form and format as agreed by you and facility.  Under federal law, however, your access to inspect or copy the following records may be limited:  psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed. Please contact our Administrator if you have questions about access to your medical record.

B.    You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and must state the specific restriction requested and to whom you want the restriction to apply.  The Facility is not required to agree to a restriction that you may request. If the Facility believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted.  If the Facility does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.   You may request a restriction by sending your written request for additional restrictions to the Administrator.

C.    You have the right to request a restriction on disclosure of PHI when paying out of pocket.  You have the right to request a restriction on the disclosure of your PHI (for payment or healthcare operations) to your health plan when you have paid for the service or item in question out of pocket in full by submitting a written request to our Administrator.  We are required to agree to this restriction.



You have the right to request confidential communications from us.  You have the right to request to receive communications from us in alternate forms or locations, or that we not provide such information to certain people.  We will accommodate reasonable requests.  We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Administrator.

E.    You may have the right to have your protected health information amended.  This means that if you have reason to believe certain PHI is incomplete or incorrect, you may request an amendment of your PHI, for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Administrator if you have questions about amending your medical record.

F.    You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you or pursuant to a written authorization signed by you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.

G.   You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.




If you believe that your privacy rights have been violated, you may file a complaint in writing with the facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the facility, contact the Administrator of the Facility who also serves as the HIPAA Compliance Officer. We will not retaliate against you if you file a complaint.




We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all PHI already received and maintained by the facility as well as for all PHI we receive in the future. We will post a copy of the current Notice in the facility. In addition, we will provide a copy of the revised Notice to all residents at the time of admission, via U.S. mail or in-house distribution.




If you have any questions about this Notice please contact the Facility Administrator by telephone or in writing at the Facility telephone number or Facility address.