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.
Effective Date of This Notice: April 14, 2003
Who Will Follow This Notice: This notice
describes the practices of our nursing facility
and of the following persons and entities:
• Any health care professional authorized to enter
information into your medical chart
• All departments and units of this facility
• Any volunteer and contractor who provides
services to you while you are in our facility
• All employees, staff and other facility personnel
• The following classes of providers, suppliers
and their employees: laboratories; physical,
occupational, speech and respiratory therapy
providers; transportation providers; radiology
providers; pharmacies; audiology providers;
dietary providers; and medical supply companies
• The following classes of individual health care
providers: attending physicians; optometrists;
ophthalmologists; dentists; podiatrists;
psychologists; and psychiatrists
All of the persons and entities noted above will
follow the terms of this notice with regard to your
health information for services provided in our
nursing facility or to you while you are a resident
in our facility regardless of where the services are
actually provided. In addition, these persons and
entities may share your health information with
each other for treatment, payment or other health
care operations purposes as described in this
notice.
How We Will Use or Disclose Your Health
Information
Treatment. We will use your health information
for treatment. For example, information obtained
by a nurse, physician, or other member of your
healthcare team will be recorded in your record
and used to determine the course of treatment
that should work best for you. Your physician will
document in your record his or her expectations of
the members of your healthcare team. Members of
your healthcare team will then record the actions
they took and their observations. In that way, the
physician will know how you are responding to
treatment. We will also provide your physician
or a subsequent healthcare provider with copies
of various reports that should assist him or her
in treating you once you’re discharged from our
facility.
Payment. We will use your health information
for payment. For example, a bill may be sent to
you or a third-party payer, including Medicare or
Medicaid. The information on or accompanying
the bill may include information that identifies
you, as well as your diagnosis, procedures and
supplies used.
Health care operations. We will use your health
information for regular health operations. For
example, members of the medical staff, the risk or
quality improvement manager, or members of the
quality improvement team may use information in
your health record to assess the care and outcomes
in your case and others like it. This information
will then be used in an effort to continually
improve the quality and effectiveness of the health
care and service we provide.
In addition, we will disclose your health information for certain health care operations
of other entities. However, we will only disclose
your information under the following conditions:
(a) the other entity must have, or have had in
the past, a relationship with you; (b) the health
information used or disclosed must relate to that
other entity’s relationship with you; and (c) the
disclosure must only be for one of the following
purposes: (i) quality assessment and improvement
activities; (ii) population-based activities relating
to improving health or reducing health care costs;
(iii) case management and care coordination; (iv)
conducting training programs; (v) accreditation,
licensing, or credentialing activities; or (vi) health
care fraud and abuse detection or compliance.
Business associates. There are some services
provided in our organization through contacts
with business associates. Examples include
accountants, consultants and attorneys. When
these services are contracted, we may disclose your
health information to our business associates so
that they can perform the job we’ve asked them to
do. To protect your health information, however,
we require the business associates to appropriately
safeguard your information.
Directory. Unless you notify us that you object, we
may use your name, location in the facility, general
condition, and religious affiliation for directory
purposes. This information may be provided to
members of the clergy and, except for religious
affiliation, to other people who ask for you by
name.
Notification. We may use or disclose information
to notify or assist in notifying a family member,
personal representative, or another person
responsible for your care, of your location and
general condition. If we are unable to reach your
family member or personal representative, then we
may leave a message for them at the phone number
that they have provided us, e.g., on an answering
machine.
Communication with family. Health professionals,
using their best judgment, may disclose to a family
member, other relative, close personal friend or
any other person you identify, health information
relevant to that person’s involvement in your care
or payment related to your care.
Marketing. We may contact you regarding your
treatment, to coordinate your care, or to direct
or recommend alternative treatments, therapies,
health care providers or settings. In addition,
we may contact you to describe a health-related
product or service that may be of interest to you,
and the payment for such product or service.
Fundraising. We may contact you or your
designated representative as part of a fundraising
effort.
Other uses & disclosures. We may use or disclose
your protected health information in the following
situations without your authorization since these
uses and disclosures are required or permitted by
law without such authorization:
• As required by law
• For public health activities, such as reporting
to the Federal Drug Administration or the
Occupational Safety and Health Administration
• About victims of abuse, neglect or domestic
violence
• For health oversight activities
• For judicial and administrative proceedings
• For law enforcement purposes
• About decedents, such as releases to coroners,
medical examiners and funeral directors
• For cadaveric organ, eye or tissue donation
purposes
• For research certain purposes where we have
permission from an institutional review board or privacy board
• To avert a serious threat to health or safety
• For specialized government functions, such as
national security
• For workers’ compensation
Your Health Information Rights
Although your health record is the physical
property of the nursing facility, the information in
your health record belongs to you. You have the
following rights:
• You may request that we not use or disclose your
health information for a particular reason related
to treatment, payment, the facility’s general
health care operations, and/or to a particular
family member, other relative or close personal
friend. We ask that such requests be made in
writing on a form provided by our facility.
Although we will consider your requests with
regard to the use of your health information,
please be aware that we are under no obligation
to accept it or to abide by it. We will abide by
your requests with regard to the disclosure of
your clinical and personal records to anyone
outside of the facility, except in an emergency, if
you are being transferred to another health care
institution, or the disclosure is required by law.
• If you are dissatisfied with the manner in
which or the location where you are receiving
communications from us that are related to your
health information, you may request that we
provide you with such information by alternative
means or at alternative locations. Such a request
must be made in writing, and submitted to the
Social Services Director. We will attempt to
accommodate all reasonable requests.
• You may request to inspect and/or obtain copies
of health information about you, which will be
provided to you in the time frames established
by law. You may make such requests orally or in
writing; however, in order to better respond to
your request we ask that you make such requests
in writing on our facility’s standard form. If
you request to have copies made, we will charge
you the community standard rate established by
state law for copies of medical records requested
from health care providers, such as hospitals and
doctors.
• If you believe that any health information in
your record is incorrect or if you believe that
important information is missing, you may
request that we correct the existing information. Such requests
must be made in writing, and must provide a
reason to support the amendment. We ask that
you use the form provided by our facility to make
such requests. For a request form, please contact
the Privacy Officer.
• You may request that we provide you with a
written accounting of all disclosures made by
us during the time period for which you request
(not to exceed 6 years). We ask that such requests
be made in writing on a form provided by our
facility. Please note that an accounting will not
apply to any of the following types of disclosures:
disclosures made for reasons of treatment,
payment or health care operations; disclosures
made to you or your Representative, or any other
individual involved with your care; disclosures
made pursuant to a valid authorization;
disclosures to correctional institutions or law
enforcement officials; and disclosures for national
security purposes. You will not be charged for
your first accounting request in any 12 month
period. However, for any requests that you make
thereafter, you will be charged a reasonable, cost based
fee.
• You have the right to obtain a paper copy of our
Notice of Privacy Practices upon request.
• You may revoke an authorization to use or disclose health information, except to the extent
that action has already been taken. Such a request
must be made in writing.
For More Information or to Report a Problem
If have questions and would like additional
information, you may contact our facility
Privacy Officer. If you believe that your privacy rights have been
violated, you may file a complaint with us. These
complaints must be filed in writing on a form
provided by our facility. The complaint form
may be obtained from Social Services, and when
completed should be returned to Social Services.
You may also file a complaint with the secretary
of the federal Department of Health and Human
Services. There will be no retaliation for filing
a complaint.
Access to Medical Records
If you desire to obtain or if you would like
someone else to obtain any information from your
medical record, you are required to complete a
written authorization form that authorizes the
facility to disclose such information. These forms
may be obtained from the Administrator or in
their absence, the Director of Nursing. In addition, you
or the person whom you authorize to access your
information must pay for any copies that they
request before those copies will be provided to
them.
Privacy Act Statement
Federal law requires that we provide you with the
following notice. We are required to comply with
that law in order to receive any payment from
Medicare or Medicaid for services provided to its
residents. This form is not a consent form to release
or use health care information pertaining to you.
1) Authority for collection of information
including social security number (SSN)
Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)
(3)(A), and 1864 of the Social Security Act.
Skilled nursing facilities for Medicare
and Medicaid are required to conduct
comprehensive, accurate, standardized, and
reproducible assessments of each resident’s
functional capacity and health status. As of June
22, 1998 all skilled nursing and nursing facilities
are required to establish a database of resident
assessment information and to electronically
transmit this information to the State. The
State is then required to transmit the data to
the federal Central Office Minimum Data Set
(MDS) repository of the Centers for Medicare
and Medicaid Services (CMS).
These data are protected under the requirements
of the Federal Privacy Act of 1974 and the MDS
Long Term Care System of Records.
2) Principal purposes for which information is
intended to be used
The information will be used to track changes
in health and functional status over time for
purposes of evaluating and improving the
quality of care provided by nursing facilitys that
participate in Medicare or Medicaid. Submission
of MDS information may also be necessary for
the nursing facilitys to receive reimbursement
for Medicare services.
3) Routine uses
The primary use of this information is to
aid in the administration of the survey and
certification of Medicare/Medicaid long term
care facilities and to improve the effectiveness
and quality of care given in those facilities.
This system will also support regulatory,
reimbursement, policy, and research functions.
This system will collect the minimum amount
of personal data needed to accomplish its stated
purpose. The information collected will be entered into
the Long Term Care Minimum Data Set (LTCMDS) system of records, System No. 09-70-
1516. Information from this system may be
disclosed, under specific circumstances, to:
(1) a congressional office from the record of
an individual in response to an inquiry from
the congressional made at the request of that
individual;
(2) the Federal Bureau of Census;
(3) the Federal Department of Justice;
(4)
an individual or organization for a research,
evaluation, or epidemiological project related
to the prevention of disease of disability, or the
restoration of health;
(5) contractors working
for CMS to carry out Medicare/Medicaid
functions, collating or analyzing data, or to
detect fraud or abuse;
(6) an agency of a State
government for purposes of determining,
evaluating and/or assessing overall or aggregate
cost, effectiveness, and/or quality of health
care services provided in the State;
(7) another
Federal agency to fulfill a requirement of a
Federal statute that implements a health benefits
program funded in whole or in part with
Federal funds or to detect fraud or abuse;
(8)
Peer Review Organizations to perform Title XI
or Title XVIII functions,
(9) another entity that
makes payment for or oversees administration of
health care services for preventing fraud or abuse
under specific conditions.
4) Whether disclosure is mandatory or voluntary
and effect on individual of not providing
information
For nursing facility residents residing in a
certified Medicare/Medicaid nursing facility the
requested information is mandatory because of
the need to assess the effectiveness and quality
of care given in certified facilities and to assess
the appropriateness of provided services. If a
nursing facility does not submit the required
data it cannot be reimbursed for any Medicare/
Medicaid services.