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CROFTONCONVALESCENT & REHABILITATION CENTER
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"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.
We are committed to preserving the privacy and
confidentiality of your health information whether created by us or maintained
on our premises. We are required by certain state and federal regulations to
implement policies and procedures to safeguard the privacy of your health
information. Copies of our privacy policies and procedures are maintained in
the business office. We are required by state and federal regulations to abide
by the privacy practices described in this notice including any future
revisions that we may make to the notice as may become necessary or as
authorized by law.
Individually identifiable information about
your past, present, or future health or condition, the provisions of health
care to you, or payment for the health care treatment or services you receive
is considered protected health information (PHI). As such, we are required to
provide you with this Privacy Notice that contains information regarding our
privacy practices that explains how, when and why we may use or disclose your
protected health information and your rights and our obligations regarding any
such uses or disclosures. Except in specified circumstances, we must use or
disclose only the minimum necessary protected health information to accomplish
the intended purpose of the use or disclosure of such information.
We reserve the right to change this notice
at any time and to make the revised or changed notice effective for health
information we already have about you as well as any information we receive in
the future about you. Should we revise/change this Privacy Notice, we will post
a copy of the new/revised Privacy Notice in the main lobby. You also may
request and obtain a copy of any new/revised Privacy Notice from the business
office.
Should you have questions concerning our
Privacy Notices, the names, addresses, telephone numbers, website addresses,
etc., of whom you should contact are listed on the last page of this document.
We use and disclose protected health
information for a variety of reasons. We have a limited right to use and/or
disclose your health information for purposes of treatment, payment, or for the
operations of our facility. For other uses, you must give us your written
authorization to release your protected health information unless the law
permits or requires us to make the use or disclosure without your
authorization.
Should it become necessary to release your
protected health information to an outside party, we will require the party to
have a signed agreement with us that the party will extend the same degree of
privacy protection to your information as we do.
The privacy law permits us to make some uses
or disclosures of your protected health information without your consent or
authorization. The following describes each of the different ways that we may
use or disclose your protected health information. Where appropriate, we have
included examples of the different types of uses or disclosures. These include:
1.
Use and Disclosures Related to Treatment:
We may disclose your
protected health information to those who are involved in providing medical and
nursing care services and treatments to you. For example we may release health
information about you to our nurses, nursing assistants, medication
aides/technicians, medical and nursing students, therapists, pharmacists,
medical records personnel, consultants, physicians, etc. We may also disclose
your protected health information to outside entities performing other services
relating to your treatment; such as diagnostic laboratories, home
health/hospice agencies, family members, etc.
2.
Use and Disclosures Related to Payment:
We may use or disclose
your protected health information to bill and collect payment for services or
treatments we provided to you. For example, we may contact your insurance
facility, health plan, or another third party to obtain payment for services we
provided to you.
3.
Use and Disclosures Related to Health Care
Operations:
We may use or disclose your protected health
information to perform certain functions within our facility should these uses
or disclosures become necessary to operate our facility and to ensure that you
and others we provide care and services to continue to receive quality care and
services. For example, we may take your photograph for medication
identification purposes or use your health information to evaluate the
effectiveness of the care and services you are receiving. We may disclose your
protected health information to our staff (nurses, nursing assistants,
physicians, staff consultants, therapists, etc.) for auditing, care planning,
treatment, and learning purposes. We may also combine your health information
with information from other health care providers to study how our facility is
performing in comparison to like facilities or what we can do to improve the
care and services we provide to you. When information is combined, we remove
all information that would identify you so that others may use the information
in developing research on the delivery of health care services without learning
your identity.
4.
Use and Disclosures Related to Fundraising
Activities:
We may use a limited amount of your protected
health information when raising money for our facility and its operations. We
may also disclose this information to a foundation related to the facility so
that the foundation may contact you to raise money on behalf of our facility.
The information we may use will be limited to your name, address, telephone
number, and dates for which you received treatment or services at our facility.
If you do not wish to be contacted for participation in fundraising activities
or have this information provided to our affiliated foundation, you must
provide us with a written notification. The name of the person to contact and
the method of contacting him/her are listed on the last page of this notice. You
may use our Request To Restrict The Use and Disclosure of Protected Health
Information form to submit your request to us. Copies of this form are
available in the business office. (See also Section VI, paragraph 1.)
5.
Use and Disclosures Related to Treatment
Alternatives, Health-Related Benefits and Services:
We may use or disclose your protected health
information for purposes of contacting you to inform you of treatment
alternatives or health-related benefits and services that may be of interest to
you. For example, a newly released medication or treatment that has a direct
relationship to the treatment or medical condition.
For uses and disclosures of your protected
health information beyond treatment, payment and operations purposes, we are
required to have your written authorization, except as permitted by law. You
have the right to revoke an authorization at any time to stop future uses or
disclosures of your information except to the extent that we have already
undertaken an action in reliance upon your authorization. Your revocation
request must be provided to us in writing. The name, address, telephone number
of the person to contact is located on the last page of this document. You may use
our Authorization for Use or Disclosure of Protected Health Information form
and/or our Revocation of an Authorization form to submit your request to us.
Copies of these forms are available in the business office.
Examples of uses or disclosures that would
require your written authorization include, but are not limited to, the
following:
1. A
request to provide your protected health information to an attorney for use in
a civil litigation claim.
2. A
request to provide certain information to an insurance or pharmaceutical
facility for the purposes of providing you with information relative to
insurance benefits or new medications that may be of interest to you.
3. A
request to provide certain information to another individual or facility.
In the following situations, we may disclose
a limited amount of your protected health information if we provide you with an
advance oral or written notice and you do not object to such release or such release
is not otherwise prohibited by law. However, if there is an emergency situation
and you are unable to object (because you were not present or you were
incapacitated, etc.), disclosure may be made if it is consistent with any prior
expressed wishes and disclosure is determined to be in your best interest. When
a disclosure is made based on these or emergency situations, we will only
disclose health information relevant to the person’s involvement in your care.
For example, if you are sent to the emergency room, we may only inform the
person that you suffered an apparent heart attack, stroke, etc., and/or we may
provide information on your prognosis or progress. You will be informed and
given an opportunity to object to further disclosures of such information as
soon as you are able to do so.
We may use or disclose
your name, unit or room number, and religious affiliation in our facility directory.
We may also disclose your religious affiliation to a member of the clergy.
Information concerning your general condition or room location may be provided
to callers or visitors when they ask for you by name. You may object to the
release of this information. You may use our Request to Restrict The Use or
Disclosure of Protected Health Information form to notify us of your objection
or your objection may be made orally. The name, address, and telephone number
of the person to whom you may make your objection is listed on the last page of
this document. (See also Section VI, paragraph 1.)
We may disclose your
protected health information to your family members and friends who are
involved in your care or who help pay for your care. We may also disclose your
protected health information to a disaster relief organization for the purposes
of notifying your family and/or friends about your general condition, location,
and/or status (i.e., alive or dead). You may object to the release of this
information. You may use our Request to Restrict The Use or Disclosure of
Protected Health Information form to notify us of your objection or your
objection may be made orally. The name, address, and telephone number of the
person to whom you may make your objection is listed on the last page of this
document. (See also Section VI, paragraph 1.)
State and federal laws and regulations
either require or permit us to use or disclose your protected health
information without your consent or authorization. The uses or disclosures that
we may make without your consent or authorization include the following:
We may disclose your protected health information
when a federal, state or local law requires that we report information about
suspected abuse, neglect, or domestic violence, reporting adverse reactions to
medications or injury from a health care product, or in response to a court
order or subpoena.
We may disclose your protected health information
when we are required to collect information about diseases or injuries (e.g.,
your exposure to a disease or your risk for spreading or contracting a
communicable disease or condition, product recalls, or to report vital
statistics (e.g., births/deaths) to the public health authority).
We may disclose your protected health information
to a health oversight agency such as a protection and advocacy agency, the
state agency responsible for inspecting our facility or to other agencies responsible
for monitoring the health care system for such purposes as reporting or
investigation of unusual incidents or to ensure that we are in compliance with
applicable state and federal laws and regulations and civil rights issues.
We may disclose your protected health information
to a coroner or medical examiner for the purpose of identifying a deceased
individual or to determine the cause of death. We may also disclose your health
information to a funeral director for the purposes of carrying out your wishes
and/or for the funeral director to perform his/her necessary duties.
If you are an organ donor, we may disclose your
protected health information to the organization that will handle your organ,
eye or tissue donation for the purposes of facilitating your organ or tissue
donation or transplantation.
We may disclose your protected health information for
research purposes only when a privacy board has approved the research project.
However, we may use or disclose your protected health information to
individuals preparing to conduct an approved research project in order to
assist such individuals in identifying persons to be included in the research
project. Researchers identifying persons to be included in the research project
will be required to conduct all activities onsite. If it becomes necessary to
use or disclose information about you that could be used to identify you by
name, we will obtain your written authorization before permitting the
researcher to use your information. Researchers will be required to sign a
Confidentiality and Non-Disclosure Agreement form before being permitted access
to health information for research purposes. A sample copy of this agreement
may be obtained from the business office.
We may disclose your protected health information
to avoid a serious threat to your health or safety or to the health or safety
of others. When such disclosure is necessary, information will only be released
to those law enforcement agencies or individuals who have the ability or
authority to prevent or lessen the threat of harm.
We may disclose protected health information of
military personnel and veterans, when requested by military command
authorities, to authorized federal authorities for the purposes of
intelligence, counterintelligence, and other national security activities (such
as protection of the President), or to correctional institutions.
You have the following rights concerning the
use or disclosure of your protected health information that we create or that
we may maintain on our premises:
You have the right to request that we limit how we
use or disclose your protected health information for treatment, payment or
health care operations. You also have the right to request a limit on the
health information we disclose about you to someone who is involved in your
care or the payment for your care or services. For example, you could request
that we not disclose to family members or friends information about a medical
treatment you received.
Should you wish a restriction placed on the use and
disclosure of your protected health information, you must submit such request
in writing. (Note: You may submit such request using our Request To Restrict
The Use and Disclosure of Protected Health Information form. Copies of this
form are available in the business office.) The name, address, and telephone
number of the person to whom the request is to be submitted is listed on the
last page of this document.
We are not required to agree to your restriction
request. However, should we agree, we will comply with your request not to
release such information unless the information is needed to provide emergency
care or treatment to you.
You have the right to inspect and copy your health
information, such as your medical and billing records that we use to make
decisions about your care and services. In order to inspect and/or copy your
health information, you must submit a written request to us. If you request a
copy of your medical information, we may charge you a reasonable fee for the
paper, labor, mailing, and/or retrieval costs involved in filing your requests.
We will provide you with information concerning the cost of copying your health
information prior to performing such service. The name, address, and telephone
number of the person to whom you may file your request is listed on the last
page of this document. You may submit your requests on our Request for
Inspection/Copy of Protected Health Information form. Copies of these forms are
available in the business office.
We will respond within thirty (30) days of receipt
of such requests. Should we deny your request to inspect and/or copy your
health information, we will provide you with written notice of our reasons of
the denial and your rights for requesting a review of our denial. If such
review is granted or is required by law, we will select a licensed health care
professional not involved in the original denial process to review your request
and our reasons for denial. We will abide by the reviewer’s decision concerning
your inspection/copy requests. You may submit your denial review requests on
our Denial of Inspection/Copy of Protected Health Information form. Copies of
these forms are available in the business office.
You have the right to request that your health information
be amended or corrected if you have reason to believe that certain information
is incomplete or incorrect. You have the right to make such requests of us for
as long as we maintain/retain your health information. Your requests must be
submitted to us in writing. We will respond within sixty (60) days of receiving
the written request. If we approve your request, we will make such
amendments/corrections and notify those with a need to know of such
amendments/corrections.
We may deny your request if:
1.
Your request is not submitted in writing;
2.
Your written request does not contain a
reason to support your request;
3.
The information was not created by us,
unless the person or entity that created the information is no longer available
to make the amendment;
4.
It is not a part of the health information
kept by or for our facility;
5.
It is not part of the information which you
would be permitted to inspect and copy; and/or
6.
The information is already accurate and
complete.
If your request is denied, we will provide you with
a written notification of the reason(s) of such denial and your rights to have
the request, the denial, and any written response you may have relative to the
information and denial process appended to your health information.
The name, address, and telephone number of the
person to whom you may file your request is listed on the last page of this
document. You may submit your amendment/correction requests on our Request for
Amendment/Correction of Protected Health Information form. Copies of these
forms are available in the business office.
You have the right to request that we communicate
with you about your health matters in a certain way or at a certain location.
For example, you may request that we not send any health information about you
to a family member’s address. We will agree to your request as long as it is
reasonably easy for us to do so. You are not required to reveal nor will we ask
the reason for your request. To request confidential communications you must:
1.
Notify us in writing;
2.
Indicate what information you wish to limit;
3.
Indicate whether or not you wish to limit or
restrict our use or disclosure of such information; and
4.
Identify to whom the restrictions apply
(e.g., which family member(s), agency, etc).
The name, address, and telephone number of the
person to whom you may file your request is listed on the last page of this
document. You may submit your requests on our Request for Restriction of
Confidential Communications form. Copies of these forms are available in the
business office.
You have the right to request that we provide you with
a listing of when, to whom, for what purpose, and what content of your
protected health information we have released over a specified period of time.
This accounting will not include any information we have made for the purposes
of treatment, payment, or health care operations or information released to
you, your family, or the facility directory, disclosures made for national
security purposes, or any releases pursuant to your authorization.
Your request must be submitted to us in writing and
must indicate the time period for which you wish the information (e.g., May 1,
2003 through August 31, 2005). Your request may not include releases for more
than six (6) years prior to the date of your request and may not include
releases prior to April 14, 2003. Your request must indicate in what form
(e.g., printed copy or email) you wish to receive this information. We will
respond to your request with sixty (60) days of the receipt of your written
request. Should additional time be needed to reply, you will be notified of
such extension. However, in no case will such extension exceed thirty (30)
days. The first accounting you request during a twelve (12) month period will
be free. There may be a reasonable fee for additional requests during the
twelve (12) month period. 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.
The name, address, and telephone number of the
person to whom you may file your request is listed on the last page of this
document. You may submit your requests on our Request for an Accounting of
Disclosures of Protected Health Information form. Copies of these forms are
available in the business office.
You have the right to receive a paper copy of this
notice even though you may have agreed to receive an electronic copy of this
notice. You may request a paper copy of this notice at anytime or you may
obtain a copy of this information from our website (as applicable). The name,
address, and telephone number of the person to whom you may obtain a paper copy
of this notice is listed on the last page of this document.
If you have reason to believe that we have
violated your privacy rights, violated our privacy policies and procedures, or
you disagree with a decision we made concerning access to your protected health
information, etc., you have the right to file a complaint with us or the
Secretary of the Department of Health and Human Services. Complaints may be
filed without fear of retaliation in any form.
The name, address, and telephone number of
the person to whom you may file your complaint is listed on the last page of
this document. You may submit your complaint on our Privacy Practices Complaint
form. Copies of these forms are available in the business office.
NOTICE OF PRIVACY PRACTICES
Name of
Resident:_____________________________________________ Date:_________________
We
are committed to preserving the privacy and confidentiality of your health
information whether created by us or maintained on our premises. We are
required by certain state and federal regulations to implement policies and
procedures to safeguard the privacy of your health information. We are required
by state and federal regulations to abide by the privacy practices described in
the notice provided to you including any future revisions that we may make to
the notice as may become necessary or as authorized by law.
The effective date of
this Privacy Notice is April 13, 2003.
We
reserve the right to change our facility’s Privacy Notice at any time and to make
the revised or changed notice effective for health information we already have
about you as well as any information we receive in the future about you. Should
we revise or change our Privacy Notice, we will post a copy of the new or
revised notice in our main lobby. You may obtain a copy of the new/revised
Privacy Notice from the business office or download a copy from our website (as
applicable).
[ ] Our Privacy Notice
was revised on _________________________. [ ] No changes since the effective
date listed above.
Should
you have any questions concerning our facility’s privacy practices, obtaining
copies of our privacy notice, requesting restrictions on the release of your
information, revoking an authorization, amending or correcting your health
information, obtaining a listing of the information we disclosed concerning
your health information, requests to inspect or copy your medical information,
requests that we communicate information about your health matters in a certain
way, denial of access to your health information, filing complaints, or any
other concerns you may have relative to our facility’s privacy practices,
please contact:
NAME OF PERSON TO
CONTACT: YOU MAY ALSO FILE
COMPLAINTS:
Suzanne Fanning, L.P.N. U.S. Depart of
Health and Human Svs
HIPAA Compliance Officer 200
Independence Avenue, S.W.
2131 Davidsonville Road Washington, DC
20201
Crofton, MD 21114
(202) 619-0257
(410) 721-1000/(301) 261-3634
Toll Free 1-877-696-6775
Fax: (410) 721-2749
I
certify that I received a copy of this facility’s Privacy Notice and that I
have had an opportunity to review this document and ask questions to assist me
in understanding my rights relative to the protection of my health information.
I am satisfied with the explanations provided to me and I am confident that the
facility is committed to protecting my health information.
Date:__________________________ My
Signature:____________________________________
My
Printed Name:________________________________
Date:__________________________ Signature of
Witness:______________________________
I
certify that I am the authorized representative of __________________________________________,
and that I have received the Privacy Notice on behalf of this individual and
that the facility provided me with an opportunity to review this document and
ask questions to assist me in understanding his/her privacy rights. I am
satisfied with the explanations provided to me and I am confident that the
facility is committed to protecting health information.
Date:__________________________ Signature of
Representative:_________________________
Printed
Name:____________________________________
Relationship
to Individual:__________________________
Date:__________________________ Signature of
Witness:______________________________
A
copy of this document must be provided to the person to whom the Privacy Notice
was provided and a copy must be filed in the medical record.