Notice of Privacy Practices Policy

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. It is important to read and understand this Notice of Privacy Practices before signing any Acknowledgment of Receipt of the Notice of Privacy Practices. If you have any questions about this Notice or would like further information concerning your privacy rights, please contact our Compliance and Ethics Officer.

This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information (PHI) that we may make. It also describes your rights to access and control your PHI and certain obligations we have regarding the use and disclosure of your protected health information. Your “protected health information” is information about you created and received by us, including demographic information that may reasonably identify you and that relates to your past, present, or future physical or mental health or condition or payment for the provision of your health care. The Privacy Rule, a federal law, gives you rights over your PHI and sets rules and limits as to who can look at and/or receive your PHI. The Privacy Rule applies to all forms of individuals’ PHI, whether electronic, written, or oral. The Security Rule is a federal law that requires security for PHI in electronic form. This Notice describes how we may use or disclose your PHI to carry out treatment, payment, or healthcare operations, as well as other purposes permitted or required by law.

We are required by law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information, to notify you following a breach of your unsecured protected health information, and to abide by the terms of the Notice that is currently in effect. We reserve the right to change the terms of this Notice, at which time, the provisions of the newer Notice will be effective for all PHI that we maintain.

Each time we provide care to you, a record is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide, and payment for the treatment. We may use and/or disclose this information:

A. To plan your care and treatment

B. To communicate with other health professionals involved in your care

C. To document the care you receive

D. To educate health professionals

E. To provide information for medical research

F. To provide information to public health officials

G. To evaluate and improve the care we provide

H. To obtain payment for the care we provide

I. For administrative purposes

A. Ensure it is accurate

B. Better understand who may access your PHI

C. Make more informed decisions when authorizing disclosure to others

The following categories describe some of the different ways that we may use or disclose your PHI. Even if not specifically listed below, the facility may use and disclose your PHI as permitted or required by law or as you authorize. We will make reasonable efforts to limit access to your PHI to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the PHI to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such use or disclosure is limited by law.

A. For Treatment - We may use and disclose your PHI to provide you with medical treatment and related services. For example, we may also use or disclose PHI about you in order to coordinate your care and provide you with medication, lab work, and x-rays. If we are permitted to do so, we may also disclose your PHI to individuals or facilities that will be involved with your care after you leave the facility and for other treatment reasons. We may also use or disclose your PHI in an emergency situation.

B. For Payment - We may use and disclose your PHI so that we can bill and receive payment for the treatment and related services you receive. For billing and payment purposes, we may disclose your health information to your payment source, including an insurance or managed care company, Medicare, Medicaid, or another third-party payor. For example, we may need to give your health plan information about the treatment you received so your health plan will pay us or reimburse us for the treatment, or we may contact your health plan to confirm your coverage or to request prior authorization for a proposed treatment.

C. For Health Care Operations - We may use and disclose your PHI for our day-to-day healthcare operations. This is necessary to ensure that you receive quality care. For example, we may use PHI for quality assessment and improvement activities and for developing and evaluating clinical protocols. We may also combine PHI about many residents to help determine what additional services we should offer, what services should be discontinued, and whether certain new treatments are effective. PHI about you may be used for business development and planning, cost management analyses, insurance claims management, risk management activities, and developing and testing information systems and programs. We may also use and disclose information for professional review, performance evaluation, and training programs. Other aspects of healthcare operations that may require the use and disclosure of your PHI include accreditation, certification, licensing and credentialing activities, review, and auditing, including compliance and ethics reviews, medical reviews, legal services, and compliance and ethics programs. Your PHI may be used and disclosed for our company's business management and general activities, including resolution of internal grievances, customer service, and due diligence in connection with a sale or transfer of our company. In limited circumstances, we may disclose your PHI to another healthcare provider subject to HIPAA for its own healthcare operations. We may remove information that identifies you so that the PHI may be used to study health care and health care delivery without learning your identity.

D. Business Associates - There may be some services provided by our business associates, such as billing services, transcription companies, or legal or accounting consultants. We may disclose your PHI to our business associates so that they can perform the job we have asked them to do. To protect your health information, we require our business associates to enter into a written contract that requires them to safeguard your information appropriately.

E. Providers - Many services provided to you as part of your care at the Facility are offered by participants in one of our organized healthcare arrangements. These participants may include a variety of providers such as physicians, therapists, psychologists, social workers, and suppliers. We may use and disclose PHI to contact you as a reminder that you have an appointment with a provider.

F. As Required by Law - We will disclose PHI about you when required to do so by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. If required by law, you will be notified of any such uses or disclosures.

G. Public Health Activities - We may disclose your PHI to prevent a serious threat to your health and safety or the health and safety of the public or another person to a public health authority that is authorized by law to collect or receive such information, such as for the purpose of preventing or controlling disease, injury or disability; reporting births, deaths or other vital statistics; reporting child abuse or neglect; notifying individuals of recalls of products they may be using; notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

H. Risk of Contracting a Communicable Disease - We may use or disclose PHI about you if you may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, so long as we are authorized by law to notify you as necessary in the conduct of a public health intervention or investigation.

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. Any disclosure, however, would be to someone able to help prevent the threat.

J. Coroners, Medical Examiners, Funeral Directors - We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose medical information to funeral directors as necessary to carry out their duties, as authorized by law.

K. Organ and Tissue Donation - If you are an organ donor, we may disclose PHI to organizations that handle organ procurement to facilitate donation and transplantation.

L. Military and National Security - If required by law, if you are a member of the armed forces, we may (1) use and disclose your PHI as required by military command authorities or the Department of Veterans Affairs; (2) disclose your PHI to authorized federal officials for the conduct of lawful intelligence, counterintelligence, and other national security activities authorized by law (3) disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations; (4) use and disclose your PHI for the purpose of a determination by the Department of Veterans Affairs, and/or to foreign military authorities if you are a member of that foreign military service, of your eligibility for benefits.

M. Research Purposes - Your PHI may be used or disclosed for research purposes, but only if the use and disclosure of your information has been reviewed and approved by a special Privacy Board or Institutional Review Board or if you provide authorization.

N. Workers’ Compensation - We may use or disclose your PHI as permitted by laws relating to workers' compensation or related programs.

O. Health Oversight Activities - We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure, and disciplinary actions.

P. Reporting Abuse, Neglect, or Domestic Violence - We may disclose your PHI to an appropriate government agency if we believe you may have been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Q. Criminal Activity - We may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of you, another person, or the public. We may also disclose PHI if it is necessary for law enforcement officials to identify or apprehend an individual.

R. Legal Proceedings - If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

S. Law Enforcement - We may disclose PHI when requested by a law enforcement official:

T. In response to a court order, subpoena, warrant, summons, or similar process, or otherwise as required by law;  (a.) To identify or locate a suspect, fugitive, material witness, or missing person;  (b.) To report gunshot wounds;  (c. To report emergencies or suspicious deaths; (d.) About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;  (e.) About a death we believe may be the result of criminal conduct; (f.) About criminal conduct at our Company; (g.) In emergency circumstances to report a crime; the location of the crime or victims; and/or the identity, description or location of the person who committed the crime; and (h.) Where there is a medical emergency (not on our Company’s premises) and it is likely that a crime has occurred.

U. National Security and Intelligence Activities - We may disclose PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

V. Food and Drug Administration - We may disclose PHI to a person or company required by the Food and Drug Administration (“FDA”) for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities, including, without limitation, to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls; to make repairs or replacement; or to conduct post-marketing surveillance, as required.

A. Treatment Alternatives and Other Health - Related Benefits and Services - We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives and to tell you about health-related benefits, services, or medical education classes that may be of interest to you. 

B. Fundraising Activities - We may use information about you to contact you in an effort to raise money for the Facility and its operations. We may share your information with our institutionally related foundation for the same purpose. The information we use, or share will be limited to your name, address, other contact information, age, gender, date of birth, dates that you received health care, department of service information, treating physician, outcome information, and health insurance status. You have the right to opt out of receiving such communications. A description of how to opt out of any fundraising communications will be included in any fundraising materials or communications that you receive. If you request that your information not be used or disclosed for fundraising purposes, we will make sure that you do not receive future fundraising communications. We may provide you with a method to opt back in to receive such communications. 

C. Facility Directory - Except for individuals admitted to a hospital for psychiatric disabilities or to a substance abuse treatment program, unless you object, we may include limited information about you in our facility directory while you are a resident at the facility, including your name, location in the facility, your general condition (e.g., fair, stable, etc.) and your religious affiliation. Except for your religious affiliation, the directory information may be released to people who ask for you by name. Your information and religious affiliation may also be given to a member of the clergy, even if the clergy member does not ask for you by name. 

D. Individuals Involved in Your Care or Payment of Your Care -  Unless you object, we may disclose your PHI to a family member, a relative, a close friend, or any other person you identify if the information relates to the person’s involvement in your health care to notify the person of your location or general condition or payment related to your health care. In addition, we may disclose your PHI to a public or private entity authorized by law to assist in a disaster relief effort. If you are unable to agree or object to such a disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object.

A. All other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization unless otherwise permitted or required by law. You may revoke your written authorization at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your authorization. 

B. Uses and Disclosures of Psychotherapy Notes -  Psychotherapy notes are notes (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private, group, or family counseling session. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and a summary of the following: diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy if it is necessary for law enforcement officials to identify or apprehend an individual. 

C. Use and Disclosure of Substance Abuse and HIV-Related Information - For disclosures concerning PHI relating to care for substance abuse or HIV-related testing and treatment, special restrictions may apply. For example, we will generally not disclose this specially protected information unless you sign a specific authorization or a court orders the disclosure. 

a. Substance abuse treatment information. If you are treated in a specialized substance abuse program, the confidentiality of alcohol and drug abuse patient records is protected by federal and state laws and regulations. Generally, we may not say to a person outside the program that you attend the program or disclose any information identifying you as an alcohol or drug abuser unless: (i.) You consent in writing (ii.) The disclosure is allowed by a court order; or (iii.) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

D. Marketing - A signed authorization is required for the use or disclosure of your PHI for a purpose that encourages you to purchase or use a product or services except for certain limited circumstances, such as when the marketing communication is face-to-face or when marketing includes the distribution of a promotional gift of nominal value provided by the Facility. An authorization is not required to describe a health-related product or service provided by use; to make communications to you regarding your treatment; or to direct or recommend alternative treatments, therapies, providers, or settings of care for you.

E. Disclosures that Constitute a Sale of PHI - A signed authorization is required for the use or disclosure of your PHI in the event that the Facility directly or indirectly receives remuneration for such use or disclosure, except under certain circumstances as allowed by federal or state law. For example, authorization is not needed if the purpose of the use or disclosure is for your treatment, public health activities, or providing you with a copy of your PHI.

A. Except as described in this Notice or as permitted by state or federal law, we will not use or disclose your PHI without your written authorization. 

B. Your written authorization will specify particular uses or disclosures that you choose to allow. Under certain limited circumstances, the Facility may condition treatment on the provision of an authorization, such as for research related to treatment. If you do authorize us to use or disclose your PHI for reasons other than treatment, payment, or healthcare operations, you may revoke your authorization in writing at any time by contacting the Facility’s Compliance and Ethics Officer. 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.

A. You have the right to request a restriction or limitation on the PHI we use or disclose about you, including information used or disclosed for the purposes of treatment, payment, or healthcare operations. You may also request that your PHI not be disclosed to family members or friends who may be involved in your care. 

B. You may request a restriction on the use or disclosure of your PHI by submitting a written request to the Facility stating (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply. 

C. We are not required to agree to your requested restriction unless it involves the disclosure of PHI to a health plan for purposes of carrying out payment or health care operations that pertain solely to a health care item or service for which the Facility has been paid out of pocket in full by you or a third party (other than the health plan) on your behalf. 

D. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you with emergency treatment. If restricted PHI is disclosed to a health care provider for emergency treatment, we will request that such health care provider not further use or disclose the information. In addition, you and the Facility may terminate the restriction if the other party is notified in writing of the termination.

You have the right to request reasonable accommodation regarding how you receive PHI communications. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. For example, you may ask that we only contact you via mail to a post office box. We will not request an explanation from you regarding the basis for the request. You must submit your request to our office in writing. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

You have the right to access, inspect, and obtain a copy of your PHI that is used to make decisions about your care for as long as the PHI is maintained by the Facility. You may not be permitted to inspect or copy psychotherapy information as follows: notes compiled or in reasonable anticipation of, or use in civil, administrative criminal, action, or proceeding. If we maintain your information electronically in a designated record set, you have the right to request an electronic copy. To access, inspect, and copy your PHI that may be used to make decisions about you, you must submit your request in writing to the Facility. If you request a copy of the information, we may charge a fee for the costs of preparing, copying, mailing, or other supplies associated with your request. We may deny, in whole or in part, your request to access, inspect, and copy your PHI under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason for the denial. You may have the right to have this denial reviewed by an independent healthcare professional designated by us to act as a reviewing official. This individual will not participate in the original decision to deny your request. You may also have the right to request a review of our denial of access through a court of law. All requirements, court costs, and attorneys' fees associated with a review of denial by a court are your responsibility. You should seek legal advice if you are interested in pursuing such rights.

You have the right to request an amendment to your PHI for as long as the information is maintained by or for the Facility. Your request must be made in writing to the Facility, and the reason for the requested amendment must be stated. We may not accept your request for an amendment if the request is not in writing or does not include a reason to support the request. We may deny your request if you ask us to amend information that (1) was not created by us unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the PHI kept by or for the Facility; or (3) is accurate and complete.

A. If we deny your request for amendment, we will provide you with a written denial, including the reasons for the refusal and information on the right to submit a written statement disagreeing with the denial. We may dispute your statement of disagreement. If you do not wish to submit a written statement disagreeing with the denial, you may request that your request for amendment and your denial be disclosed with any future disclosure of your relevant information.

You have the right to receive an accounting of certain disclosures of your PHI by the Facility or by others on our behalf. To request an accounting of disclosures, you must submit a request in writing, stating a time period within six (6) years from your request. The first accounting provided within a twelve-month period will be free. We may charge you a reasonable, cost-based fee for each future request for an accounting within a single twelve-month period. However, you will be allowed to withdraw or modify your request for an accounting of disclosures to avoid or reduce the fee. In the event the Facility maintains an electronic health record, an accounting of disclosures from the electronic health record related to treatment, payment, or health care operations will be made only for the three (3)-year period preceding the request.

If there is a breach of your PHI, you will be notified within a reasonable amount of time, as required by law.

Upon request, you have the right to receive a copy of revised Notices on or after the effective date of revision. Additionally, the revised Notice will be posted in a clear and prominent location.

You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting the facility. In addition, you have the right to receive a copy of this Notice when the Facility seeks additional consent.

You may file a complaint with us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may also file a complaint with us by notifying our Compliance and Ethics Officer in writing of your complaint. You will not be penalized or retaliated against for filing a complaint, and we will make every reasonable effort to resolve your complaint with you.