Notice of Privacy 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.
Our Facility has a longstanding commitment to protecting the privacy of individually identifiable health information, also referred to as Protected Health Information (“PHI”). A part of this commitment involves compliance with the privacy standards contained in the regulations promulgated under the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act, and regulations promulgated thereunder (collectively referred to as “HIPAA”). This statement generally describes the requirements of HIPAA.
Our Facility is required by law to provide you with this notice so that you will understand how we may use or share your medical information. We are required to adhere to the terms outlined in this notice. If you have any questions about this notice, please contact the Facility Administrator. You may request a copy of this notice at any time.
HIPAA establishes a federal floor of safeguards to protect the confidentiality of medical information. State laws may provide stronger privacy protections and apply over and above federal privacy standards. HIPAA gives patients more control over their PHI. It sets boundaries on the use and release of health records. It establishes safeguards that health care providers must achieve to protect the privacy of PHI. It holds violators accountable, with civil and criminal penalties that can be imposed if providers violate patients’ privacy rights. It enables patients to find out how their information may be used and what disclosures of their information have been made. It generally limits release of information to the minimum necessary for the purpose of the disclosure. It gives patients the right to examine and obtain a copy of their own health records and request corrections. This Notice applies to all the PHI that we generate and to substance use treatment-related records (substance use treatment records) under 42 U.S.C. §290dd-2 and 42 C.F.R. Part 2 (Part 2) that we receive or maintain. We also follow the confidentiality protections of Part 2 for such records.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in Facility. The notice will specify the effective date on the first page in the top right-hand corner. In addition, if material changes are made to this notice, the notice will contain an effective date for the revisions and copies can be obtained by contacting the Facility Administrator.
UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION
Each time you visit our Facility, a record of your visit is made. Typically, this record contains information about your condition and the treatment that we provide. We use and/or disclose this information to:
Plan our care and treatment
Communicate with other health professionals involved in your care
Document the care you receive
Educate health professionals
Provide information for medical research
Provide information to public health officials
Evaluate and improve the care we provide
Understanding what is in your record and how your health information is used helps you to:
Ensure the information is accurate
Better understand who may access your health information
Make more informed decisions when authorizing disclosure to others
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe the way we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall into one of the categories.
For Treatment: We may use medical information about you to provide you with medical treatment. We may disclose medical information about you to doctors, nurses, therapists, or other facility personnel who are involved in taking care of you at our Facility. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can plan your meals. Different departments of our Facility also may share medical information about you to coordinate your care and provide you medication, lab work, and X-rays. We may also disclose medical information to people outside Facility who may be involved in your medical care after you leave Facility. This may also include family members or visiting nurses who provide care in your home.
For Payment: We may use and disclose medical information about you so that the treatment and services you receive at Facility may be billed to you, an insurance company, or a third party. For example, to be paid, we may need to share information with your health plan about services we provided to you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations: We may use and disclose medical information about you for health care operations. This is necessary to ensure that all our residents receive quality care. For example, we may use medical information to review our services and to evaluate the performance of our staff. We may also combine medical information about many residents to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, therapists, and other facility personnel for review and learning purposes. We may remove information that identifies you so others may use it to study health care and health care delivery without learning the identities of residents.
OTHER ALLOWABLE USES OF YOUR MEDICAL INFORMATION
Business Associates. There are some services provided in our organization through contracts with business associates. Examples include medical directors, outside attorneys, copy services when making copies of your health records, and registered dietitians. When these services are contracted, we may disclose your health information to these business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard your information.
Providers. Many services provided to you as part of your care at our Facility are offered by participants in one of our organized healthcare arrangements. These participants include a variety of providers, such as physicians (e.g., MD, DO, Podiatrist, Dentist, Optometrist), therapists (e.g., Physical Therapist, Occupational Therapist, Speech Therapist), portable radiology units, clinical labs, hospice caregivers, pharmacies, psychologists, licensed clinical social workers, and suppliers (e.g., Prosthetic, Orthotics).
Treatment Alternatives. We may use and disclose medical information to tell you about possible treatment options or alternatives that may be of interest.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest.
Facility Directory. We may include information about you in the Facility directory while you are a resident. This information may include your name, location in Facility, your general condition (e.g., fair, stable, etc.) and your religion. The directory information, except for your religion, may be disclosed to people who ask for you by name. Your religion may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends, and clergy members can visit you in Facility and generally know how you are doing.
Individuals Involved in Your Care or Payment for Care. We may disclose medical information about you to a friend or family member who is involved in your care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in our Facility. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you to prevent a serious threat to your health and safety or the health and safety of the public or another person. We would do this only to help prevent the threat.
Restrictions. We will never sell your information, share it for marketing purposes, or share psychotherapy notes without your written permission. We may contact you for fundraising efforts, but you can tell us not to contact you again.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. We will notify you promptly if any breach occurs that may have compromised the privacy or security of your PHI.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Although your health record is the property of Facility, You have the following rights regarding your medical information:
Right to Request Record. You can ask to see or get an electronic or paper copy of your medical record and other health information about you. We will provide this information within 30 days of your request. If we need additional time to provide this information, we will send you a notice informing you of this and extending the time we have to provide the record for up to 30 days.
Right to Amend. If you feel that medical information in your record is incorrect or incomplete, you may ask us to amend the information. You have this right to amend as long as the information is kept by or for Facility. You must submit your request in writing to the Facility Administrator. In addition, you must provide a reason for your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information:
That was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
That is not part of the medical information kept by or for Facility; or
To something that is not accurate and/or complete.
If we deny your request to amend your record, we will tell you why within 60 days.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of certain disclosures we made of your medical information, other than those made for purposes such as treatment, payment, or health care operations. You must submit your request in writing to the Facility Administrator. Your request must state a time period which may not be longer than six (6) years from the date the request is submitted. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve (12) month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you. For example, you may request that we limit the medical information we disclose to someone who is involved in your care or the payment of your care. We are not required to agree to your request and may say “no” if we feel it may impact your care. You must submit your request in writing to the Facility Administrator. In your request, you must tell us (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 (for example, your spouse).
If you pay for an item or service out-of-pocket in full, you may ask us not to share information about that item or service for the purpose of payment or our operations with your health insurer. We will agree to this request unless a law requires us to share that information.
Right to Request Confidential Communications. You may ask us to contact you in a specific way or to send mail to a specific address. We will agree to all such reasonable requests.
Choose Someone to Act for You. If you have given medical power of attorney to someone or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action they instruct us to take.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all residents who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with residents’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project so long as the medical information they review does not leave Facility.
Workers’ Compensation. We may disclose medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose medical information about you for public health purposes, including:
Prevention or control of disease, injury, or disability.
Reporting births and deaths.
Reporting reactions to medications or problems with products.
Notifying people of recalls of products.
Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.
Notifying the appropriate government authority if we believe a resident has 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.
With organ procurement organizations.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information 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.
Law Enforcement. We may disclose medical information when requested by a law enforcement official:
In response to a court order, subpoena, warrant, summons, or similar process.
To identify or locate a suspect, fugitive, material witness, or missing person.
About you, the victim of a crime if, under limited circumstances, we are unable to obtain your agreement.
About a death we believe may be the result of criminal conduct.
About criminal conduct at our Facility.
In emergency circumstances to report a crime, the location of the crime or victims, the identity, description, or location of the person who committed the crime.
Coroners, Medical Examiners, and Funeral Directors. We may disclose medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also disclose medical information to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Substance Abuse Treatment Records. If any of your records are substance abuse treatment records subject to the protections of 42 CFR part 2, you have a right to adequate notice of the use and disclosure of such records. If the provisions of 42 CFR part 2 restrict our use and/or disclosure of your health information in ways that would otherwise be required or permitted by this notice and/or other applicable law, the provisions of 42 CFR part 2 shall control and prevent or limit such use and/or disclosure. For example, substance use disorder treatment records received from programs subject to 42 CFR part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against You unless based on written consent, or a court order after notice and an opportunity to be heard is provided to You or the holder of the record, as provided in 42 CFR part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed. You may revoke your authorization at any time, but it will not affect information that we already used and disclosed.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by mailing a letter to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201, by emailing ocrcomplaint@hhs.gov, or by visiting www.hhs.gov/hipaa/filing-a-complaint/index.html. To file a complaint with us, contact our Privacy Officer at (540) 777-9265. WE WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.
Effective Date: February 15, 2026