Notice of Privacy Practices
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 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. 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 to the
notice as may become necessary or as authorized by law.
Individually identifiable information about your
past, present, or future health or condition, the provisions 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 that contains information
regarding our privacy practices that explains how, when and why we may use or
disclose your protected health information and your rights and our obligations
regarding any such uses or disclosures. Except in specified
circumstances, we must use or disclose only the minimum necessary protected
health information to accomplish the intended purpose of the use or disclosure
of such information.
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 in the future
about you. Should we revise/change this Privacy Notice, we will post a copy of
the new/revised Privacy Notice at our offices. You also may request and obtain
a copy of any new/revised Privacy Notice from the business office.
Should you have questions concerning our Privacy
Notices, the names, addresses, telephone numbers, website addresses, etc., of
whom you should contact are listed on the last page of this document.
II.
How We May Use and Disclose Your Protected Health Information
We use and disclose protected health information for
a variety of reasons. We have a limited right to use and/or disclose your
health information for purposes of treatment, payment, or for the operations of
our facility. For other uses, you must give us your written authorization to
release your protected health information unless the law permits or requires us
to make the use or disclosure without your authorization.
Should it become necessary to release your protected
health information to an outside party, we will require the party to have a
signed agreement with us that the party will extend the same degree of privacy
protection to your information as we do.
The privacy law permits us to make some uses or
disclosures of your protected health information without your consent or
authorization. The following describes each of the different ways that we may
use or disclose your protected health information. Where appropriate, we have
included examples of the different types of uses or disclosures. These include:
1.
Use and Disclosures Related to Treatment:
We may disclose your
protected health information to those who are involved in providing medical and
nursing care services and treatments to you. For example we may release health
information about you to our nurses, nursing assistants, medication
aides/technicians, medical and nursing students, therapists, pharmacists,
medical records personnel, consultants, physicians, etc. We may also disclose
your protected health information to outside entities performing other services
relating to your treatment; such as diagnostic laboratories, home
health/hospice agencies, family members, etc.
2.
Use and Disclosures Related to Payment:
We may use or disclose your
protected health information to bill and collect payment for services or
treatments we provided to you. For example, we may contact your insurance
facility, health plan, or another third party to obtain payment for services we
provided to you.
3.
Use and Disclosures Related to Health Care
Operations:
We may use or disclose your protected health information to perform
certain functions within our facility should these uses or disclosures become
necessary to operate our facility and to ensure that you and others we provide
care and services to continue to 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 are receiving. We may disclose your protected health information
to our staff (nurses, nursing assistants, physicians, staff consultants,
therapists, etc.) for auditing, care planning, treatment, and learning
purposes. We may also combine your health information with information from
other health care providers to study how our facility is performing in
comparison to like facilities or what we can do to improve the care and
services we provide to you. When information is combined, we remove all
information that would identify you so that others may use the information in
developing research on the delivery of health care services without learning
your identity.
4.
Use and Disclosures Related to Treatment
Alternatives, Health-Related Benefits and Services:
We may use or disclose your protected health information for purposes
of contacting you to inform you of treatment alternatives or health-related
benefits and services that may be of interest to you. For example, a newly released
medication or treatment that has a direct relationship to the treatment or
medical condition.
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, 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.
Examples of uses or disclosures that would require
your written authorization include, but are not limited to, the following:
1.
A request to provide your protected health information to an attorney
for use in a civil litigation claim.
2.
A request to provide certain information to an insurance or
pharmaceutical facility for the purposes of providing you with information
relative to insurance benefits or new medications that may be of interest to
you.
3.
A request to provide certain information to another individual or
facility.
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 an
advance oral or written notice and you do not object to such release or 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 disclosure is 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 only inform
the person that you suffered an apparent heart attack, stroke, etc., and/or we
may provide information on your prognosis or progress. You will be informed and
given an opportunity to object to further disclosures of such information as
soon as you are able to do so.
- Information Used or Disclosed in the Facility
Directory:
We may use or disclose your
name, unit or room number, and religious affiliation in our facility 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 is listed on
the last page of this document. (See also Section VI, paragraph 1.)
- 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. 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 dead). 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. (See also Section VI, paragraph 1.)
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:
- When Required by Law:
We may disclose your protected health information when a federal, state
or local law requires that we report information about suspected abuse,
neglect, or domestic violence, reporting adverse reactions to medications or
injury from a health care product, or in response to a court order or subpoena.
- For Public Health Activities for the Purpose of
Preventing or Controlling Disease, Injury or Disability:
We may disclose your protected health information when we are 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 (e.g., births/deaths)
to the public health authority).
- 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 facility or to other agencies responsible for monitoring the
health care system for such purposes as reporting or investigation of unusual incidents
or to ensure that we are in compliance with applicable state and federal laws
and regulations and civil rights issues.
- 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 for the purpose of identifying a deceased individual or to
determine the cause of death. We may also disclose your health information to a
funeral director for the purposes of carrying out your wishes and/or for the
funeral director to perform his/her necessary duties.
If you are an organ donor, we may disclose your protected health
information to the organization that will handle your organ, eye or tissue
donation for the purposes of facilitating your organ or tissue donation or
transplantation.
- For Research Purposes:
We may disclose your protected health information for research purposes
only when a privacy board has approved the research project. However, we may
use or disclose your protected health information to individuals preparing to
conduct an approved research project in order to assist such individuals in
identifying persons to be included in the research project. Researchers
identifying persons to be included in the research project will be required to
conduct all activities onsite. If it becomes necessary to use or disclose
information about you that could be used to identify you by name, we will
obtain your written authorization before permitting the researcher to use your
information. Researchers will be required to sign a Confidentiality and
Non-Disclosure Agreement form before being permitted access to health
information for research purposes. A sample copy of this agreement may be
obtained from the business office.
- To Avert a Serious Threat to Health or Safety:
We may disclose your protected health information to avoid a serious
threat to your health or safety or to the health or safety of others. When such
disclosure is necessary, information will only be released to those law
enforcement agencies or individuals who have the ability or authority to
prevent or lessen the threat of harm.
- 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 the purposes of intelligence, counterintelligence, and other
national security activities (such as protection of the client/resident), or to
correctional institutions.
VI.
Your Right 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:
- 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.
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. (Note:
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.
- The 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 filing 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 of 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.
- The 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:
a.
Your request is not submitted in writing;
b.
Your written request does not contain a reason to support your request;
c.
The information was not created by us, unless the person or entity that
created the information is no longer available to make the amendment;
d.
It is not a part of the health information kept by or for our facility;
e.
It is not part of the information which you would be permitted to
inspect and copy; and/or
f.
The information is already accurate and complete.
If your request is denied, we will provide you with a written
notification of the reason(s) of 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.
- The 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. You are not required to reveal nor will we ask the reason for your
request. To request confidential communications you must:
a.
Notify us in writing;
b.
Indicate what information you wish to limit;
c.
Indicate whether or not you wish to limit or restrict our use or
disclosure of such information; and
d.
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.
- The 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 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
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.
- The 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 anytime 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 on the last page of this document.
VI.
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 on the last page of
this document. You may submit your complaint on our Privacy Practices
Complaint form. Copies of these forms are available in the business office.
Effective
Date of This Privacy Notice
The effective date of this Privacy Notice is
Privacy
Notices, Information Restrictions, Record Amendments/Corrections, Disclosures
of Information, Revoking an Authorization, Inspection and Copying of Records,
Confidential Communications, Filing Complaints, Etc.
Should
you have any questions concerning our agency’s/facility’s privacy practices,
obtaining copies of our privacy notice, requesting restrictions on the release
of your information, revoking an authorization, amending or correcting your
health information, obtaining a listing of the information we disclosed
concerning your health information, requests to inspect or copy your medical
information, requests that we communicate information about your health matters
in a certain way, denial of access to your health information, filing
complaints, or any other concerns you may have relative to our
agency’s/facility’s privacy practices, please contact:
YOU
MAY ALSO FILE COMPLAINTS WITH:
jwb@madiganestates.com
Toll
Free