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.
Each time you visit a nursing facility, a record of
your visit is made. Typically, this record contains your symptoms,
examination and test results, diagnoses, treatment, and a plan for
future care or treatment. This information, often referred to as your
health or medical record, serves as a:
› basis of planning your care and treatment
› means of communication among the many health professionals
who contribute to your care
› legal document describing the care you received
› means by which you or a third-party payer can verify
that services billed were actually provided
› a tool in educating health professionals
› a source of data for medical research
› a source of information for public health officials
who oversee the delivery of health care in the United States
› a source of data for facility planning and marketing
› a tool with which we can assess and continually work
to improve the care we render and the outcome we achieve
Understanding what is in your record and how your health
information is used helps you to: ensure its accuracy, better understand
who, what, when, where, and why others may access your health information,
and make more informed decisions when authorizing disclosure to others.
Our nursing facility is required to:
› maintain the privacy of your health information
› provide you with a notice as to our legal duties and
privacy practices with respect to information we collect and maintain
about you
› abide by the terms of this notice
› notify you if we are unable to agree to a requested
restriction
› accommodate reasonable requests you may have to communicate
health information by alternative means or at alternative locations.
We reserve the right to change our practices and to
make the new provisions effective for all protected health information
we maintain. Should our information practices change, we will mail
you a revised notice.
We will not use or disclose your health information
without your authorization, except as described in this notice.
(1) 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 nursing facility.
(2) 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.
(3) 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.
(4) Business associates. There are some services provided
in our organization through contracts with business associates. Examples
include our 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.
(5) 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. We may also
use your name on a nameplate next to or on your door in order to identify
your room, unless you notify us that you object.
(6) Notification. We may use or disclose information
to notify or to 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.
(7) 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.
(8) Research. We may disclose information to researchers
when their research has been approved by an institutional review board
that has reviewed the research proposal and established protocols
to ensure the privacy of your health information.
(9) Funeral directors. We may disclose health information
to funeral directors and coroners to carry out their duties consistent
with applicable law.
(10) Organ procurement organizations. Consistent with
applicable law, we may disclose health information to organ procurement
organizations or other entities engaged in the procurement, banking,
or transplantation of organs for the purpose of tissue donation and
transplant.
(11) Marketing. We may contact you to provide appointment
reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
(12) Fund raising. We may contact you as part of a fund-raising
effort.
(13) Food and Drug Administration (FDA). We may disclose
to the FDA health information relative to adverse events with respect
to food, supplements, product and product defects, or post marketing
surveillance information to enable product recalls, repairs, or replacement.
(14) Workers compensation. We may disclose health information
to the extent authorized by and to the extent necessary to comply
with laws relating to workers compensation or other similar programs
established by law.
(15) Public health. As required by law, we may disclose
your health information to public health or legal authorities charged
with preventing or controlling disease, injury, or disability.
(16) Correctional institution. Should you be an inmate
of a correctional institution, we may disclose to the institution
or agents thereof health information necessary for your health and
the health and safety of other individuals.
(17) Law enforcement. We may disclose health information
for law enforcement purposes as required by law or in response to
a valid subpoena.
(18) Reports. Federal law makes provision of your health
information to be released to an appropriate health oversight agency,
public health authority or attorney, provided that work force member
or business associate believes in good faith that we have engaged
in unlawful conduct or have otherwise violated professional or clinical
standards and are potentially endangering one or more patients, workers
or the public.
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 request, please be aware that we are
under no obligation to accept it or to abide by it. For more information
about this right, see 45 Code of Federal Regulations (C.F.R.) 164.522(A).
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 Facility
Privacy Officer. We will attempt to accommodate all reasonable requests.
For more information about this right, see 45 C.F.R. 164.5322(b).
You may request to inspect and/or obtain copies of health
information about you, which will provided to you in the time frames
established by law. If you request copies, we will charge you a reasonable
fee. For more information about this right, see 45C.F.R 164.524. 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 or add the missing 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. For more information about this right, see 45
C.F.R. 164.526.
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 legal representative,
or any other individual involved with your care; disclosures to correctional
institutions or law enforcements 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.
For more information about this right, see 45 C.F.R. 164.528.
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.
If you have questions and would like additional information,
you may contact our facility's Privacy Officer at 815-727-8710.
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 Facility's Administration Office, and when completed
should be returned to Facility attention Privacy Officer. 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.