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.

 

We have summarized our responsibilities and your rights on this first page.  For a complete description of our privacy practices, please review the entire notice.

 

OUR RESPONSIBILITIES

 

Our Nursing facility is required to:

• Maintain the privacy of your health information

• Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you

• Abide by the terms of this notice

YOUR RIGHTS

 

As a resident of Menard Manor, you have several rights with regard to your health information including the following:

• The right to request that we not use or disclose your health information in certain ways

• The right to request to receive communications in an alternative manner or location

• The right to access and obtain a copy of your health information

• The right to an accounting of disclosures of your health information

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain.  Should our privacy practices change, we will post the changes on the bulletin board in our facility, as well as our Web site.  A copy of the revised notice will be available after the effective date of change upon request.

 

We will not use or disclose your health information without your authorization, except as described in this notice.

 

If you have questions and would like information, you may contact our facility’s Privacy Officer, Dava Owen at (325) 396-4541.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION

 

Each time you are admitted to a nursing facility, a record of your stay is made.  Typically, this record contains your symptoms, examination and test results, diagnosis, treatment and plan for future care or treatment.  This information, often referred to as your health or medical record, serves as a:

• basis for 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 outcomes 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 informed decisions when authorizing disclosures to others.

 

HOW WE WILL USE OR DISCLOSE YOUR HEALTH INFORMATION
 

1.  Treatment:  We will use and disclose your personal health information in providing you with treatment and services.  We may disclose your personal health information 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 changes in your condition to you physician.  We may also disclose personal health information to individuals who            

 

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

 

3.  Health Care Operations: We will use or disclose your health information for our regular health care 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 care and services 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 disclosures 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.

 

4.  Business Associated:  There are some services provided in our organization through the use of outside people and entities, examples of those “Business Associates” include our accountants, consultants, and attorneys.  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, 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 assist in notifying a family member, personal representative, or other 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.  Communications with Family:  We may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health care 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 certain conditions have been met.

 

9.  Transfer of Information at Death:  We may disclose health information to the Funeral Director, Medical Examiners, and coroners to carry out their duties consistent with applicable laws.

 

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.  Treatment Alternatives:  We may use or disclose personal health information to inform you about treatment alternatives that may be of interest to you.

 

12.  Fund Raising:  We may use certain personal health information to contact you in an effort to raise money for the facility and its operations.  We may disclose personal health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility.  In doing so, we would only release contact information, such as your name, address, telephone number and the dates you received treatment or services at the facility.

 

13.  Food and Drug Administration (FDA):  We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable to product recalls, repairs or replacements.

 

14.  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.

 

15.  Law Enforcement:  We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

 

16.  Reports:  Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce 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.

 

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

 

18.  Appointment Reminders:  We may use or disclose personal health information to remind you about appointments.

 

19.  Health Related Benefits and Services:  We may use or disclose personal health information to inform you about health-related benefits and services that may be of interest to you.

 

YOUR HEALTH INFORMATION RIGHTS

 

You have the following rights regarding your personal health information at this facility.

 

Right to Request Restrictions:  You have the right to request restrictions on or our use and disclosure of your personal health information for treatment, payment, and health care operations.  You also have the right to restrict the personal health information we disclose about you to a family member, friend or person involved in your care.

 

We are not required to agree to your requested restriction (except that while you are competent you may restrict disclosures to family members or friends).  If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

 

Right to Request Amendment:  You may have the right to request the facility to amend any personal health information maintained by the facility for as long as the information is kept by or for the facility.  Your request must be made in writing and must state the reason for the requested amendment.

 

We may deny your request for amendment if the information:

• was not created by the facility, unless the originator of the information is no longer available to act on your request;

• is not part of the personal health information maintained by or for the facility

• is not part of the information to which you have a right to access; or

• is already accurate and complete, as determined by the facility.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

 

Right to an Accounting of Disclosures:  You have the right to request an “accounting” of our disclosures of your personal health information.  This is a listing of certain disclosures of your personal health information made by the facility or by others on our behalf, but does not include disclosures for treatment, payment and health care operations.

 

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request.  An accounting will include, if requested:  the disclosure date; the name of the person or entity that received the information, and address, if known; a brief description of the information disclosed, a brief statement of the purpose of the disclosure or a copy of the authorization or request; or certain summary information concerning multiple similar disclosures.  The first accounting provided within a 12 month period will be free; for further request we may charge you our costs.

 

Right to Paper Copy of this Notice:  You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.  You may also access and print a copy of our notice from our Web site www.menardmanor.org.

 

FOR MORE INFORMATION OR TO REPORT A PROBLEM

 

If you have questions and would like additional information, you may contact our facility’s Privacy Officer at (325) 396-4541.

 

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 Dava Owen, Privacy Officer, and when completed should be returned to her.  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.

 

Effective Date:   04-04-03