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.
ABOUT THIS NOTICE
Shiloh Place ALF and Shiloh Center ADS is strongly committed to protecting your health information. This Notice of Privacy Practices (“Notice”) is provided pursuant to the Health Insurance Portability and Accountability Act of 1996 and describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights and our duties with respect to your protected health information. “Protected health information” is information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We must follow the privacy practices that are described in this Notice while it is in effect. If you have any questions about this Notice, please contact your Executive Director, who acts as the Community Privacy Representative.
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following categories describe the different ways that we may use and disclose your protected health information. These examples are not meant to be exhaustive, but to illustrate the types of uses and disclosures that may be made by Sunrise. However, Shiloh Place may never have a reason to make some of these disclosures.
1. For Treatment
We may use and disclose your protected health information to provide, coordinate, or manage your health care treatment and any related services. We may also disclose your protected health information to other third party providers involved in your health care. For example, your protected health information may be provided to a physician or other health care provider (e.g. a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you.
2. For Payment
We may use and disclose your protected health information so that the treatment and health care services you receive may be billed to you, your insurance company, a government program, or third party payers. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services recommended for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may provide your health plan with medical information about the health care services Shiloh Place rendered to you for reimbursement purposes.
3. For Health Care Operations
We may use and disclose your protected health information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our residents receive quality care and for our operation and management purposes. For example, we may use your protected health information to review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose information to doctors, nurses, technicians, medical students, and other personnel for educational and learning purposes.
4. Treatment Communications
We may send you treatment communications concerning treatment alternatives or other health related products or services for which we may receive payment in exchange for making the communication. If you do not wish to receive these communications please submit a written request to the Administrator.
5. Resident Directory
Unless you object, we may use and disclose in our resident directory your name, your location in the community, your general condition and your religious affiliation. All of this information, except religious affiliation, may be disclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may take your photo, use it to comply with Medication Room Policies, and will hang it on the wall – with your approval.
6. Others Involved in Your Healthcare
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify a family member, personal representative or any other person that is responsible for your care of your general condition, status, and location. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
7. Required by Law
We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
8. Public Health
We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
9. Business Associates
We may disclose your protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. To protect your health information, however, we require the business associate to appropriately safeguard your information.
10. Communicable Diseases
We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
11. Health Oversight
We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
12. Abuse or Neglect
We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
13. Food and Drug Administration
We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required by law.
14. Legal Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request or other lawful process.
15. Law Enforcement
We may disclose your protected health information, so long as applicable legal requirements are met, for law enforcement purposes.
16. Coroners, Funeral Directors, and Organ Donation
We may disclose your protected health information 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 your protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out its duties. We may disclose such information in reasonable anticipation of death.
Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
We may disclose your protected health 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 protected health information.
18. Serious Threat to Health or Safety
Consistent with applicable federal and state laws, we may disclose your protected health information to prevent or lessen a serious threat to your health and safety or to the health and safety of another person or the public.
19. Military Activity and National Security
If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your protected health information to authorized officials so they may carry out their legal duties under the law.
20. Workers’ Compensation
We may disclose your protected health information as authorized for workers’ compensation or other similar programs that provide benefits for a work-related illness.
21. For Data Breach Notification Purposes
We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.
22. Required Uses and Disclosures
Under the law, we must make disclosures to you and when required by the Secretary of the
U.S. Department of Health and Human Services to investigate or determine our compliance.
SPECIAL PROTECTIONS FOR HIV, ALCOHOL AND SUBSTANCE ABUSE, MENTAL HEALTH AND GENETIC INFORMATION
Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this Notice may not apply to these types of information.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN AUTHORIZATION
The following uses and disclosures will be made only with your written authorization:
- 1. Most uses and disclosures of psychotherapy notes;
- 2. Uses and disclosures of protected health information for marketing purposes; and
- 3. Disclosures that constitute a sale of protected health information.
Other uses and disclosures of your protected health information not described in this Notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that Shiloh Place has taken an action in reliance on the use or disclosure indicated in the authorization. Additionally, if a use or disclosure of protected health information described above in this Notice is prohibited or materially limited by other laws that apply to use, it is our intent to meet the requirements of the more stringent law.
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
1. Right to be Notified if there is a Breach of Your Protected Health information
You have the right to be notified upon a breach of any of your unsecured protected health information.
2. Right to Inspect and Copy
You may inspect and obtain a copy of your protected health information that is contained in your medical and billing records and any other records that Shiloh Place uses for making decisions about you. To inspect and copy your medical information, you must submit a written request to the Administrator. If you request a copy of your information, we may charge you a reasonable fee for the costs of copying, mailing or other costs incurred by us in complying with you request. Under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, we may deny your request to inspect and/or copy your protected health information. A decision to deny access may be reviewable. Please contact the Administrator if you have questions about access to your medical record.
3. Right to Request Restrictions
You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. To request a restriction on who may have access to your protected health information, you must submit a written request to the Administrator. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Shiloh Place is not required to agree to a restriction that you may request, unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we believe it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. If we do agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.
4. Right to Request Confidential Communication
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. You must request this by submitting a written request to the Administrator.
5. Right to Request Amendment
You may request an amendment of your protected health information contained in your medical and billing records and any other records that Shiloh uses for making decisions about you, for as long as we maintain the protected health information. You must request for an amendment by submitting a written request to the Administrator, and provide the reason(s) that support your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
6. Right to an Accounting of Disclosures
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. You must request for an accounting of disclosures by submitting a written request to the Administrator, and provide the reason(s) that support your request.
7. Right to Obtain a Paper Copy of this Notice
You have the right to receive a paper copy of this Notice even if you have agreed to receive this notice electronically. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this Notice, you can contact the Administrator.
COMPLAINTS OR QUESTIONS
If you believe your privacy rights have been violated, you may complain to us or to the NE Department of Health and Human Services. If you have a question about this Notice or wish to file a complaint with us, please contact the Administrator. All complaints must be submitted in writing. Shiloh Place ALF and Shiloh Center ADS will not retaliate against you for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. The new Notice will be effective for all health information we already have about you as well as any information we receive in the future. You can also obtain a revised Notice by contacting the Administrator or the Corporate Office at the address listed below.
Shiloh Place Assisted Living, 915 North H Street, Fremont, Nebraska 68025 Tel: 402-208-8859 Fax: 402-721-9170 Email: firstname.lastname@example.org
Nebraska Department of Health and Human Services
301 Centennial Mall South
Lincoln, NE 68509
This Notice is effective as of March 12, 2014.
Shiloh Place Assisted Living Shiloh Center Adult Day Service
I,_______________________________________________ hereby acknowledge that I have received and reviewed a copy of Shiloh Place ALF /Shiloh Center ADS Notice of Privacy Practices.
I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request. A current Notice of Privacy Practices is posted at www.shilohplaceassistedliving.com
Resident Name: ___________________________________________________________________
Signature: Date: ___________________________________________________________________
Personal Representative (Required if the resident is an adult unable to sign): Name of: Representative:_____________________________________________________________________Relationship to Resident:______________________________________________________________ Signature:__________________________________________________________________________