WESLEY HEALTH CARE CENTER, INC. (Revised 9.23.13)
WESLEY HEALTH CARE CENTER, INC.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (the person receiving care and services) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We respect the privacy of your personal health information and are committed to maintaining our Patient’s and Resident’s confidentiality. This Notice applies to all information and records related to your care that our facility has received or created. It extends to information received or created by our employees, staff, consultants, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your personal health information. It also describes your rights and our obligations regarding your personal health information.
We are required by law to:
Maintain the privacy of your protected health information;
Provide to you this Notice of our legal duties and privacy practices relating to your personal health information;
notify you in the event of a breach involving your unsecured health information; and
Abide by the terms of the Notice that are currently in effect.
Except as may be otherwise required by law, our obligations and your rights under this Notice terminate after fifty (50) years after your death.
Affiliated Covered Entities
: This privacy notice applies to Wesley Health Care Center, Inc. and Evergreen Adult Day Care, Inc. who have designated themselves as affiliated covered entities Affiliated covered entities are considered as one covered entity for HIPAA privacy purposes. Affiliated covered entities may share information amongst themselves as permitted by law, including for purposes of treatment, payment and health care operations.
1. WE MAY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
You will be asked to sign a receipt indicating you have received this notice. This notice informs you about our practices, policies and requirements related to the use and disclosure of your personal health information for purposes of treatment, payment and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories.
For Treatment. We will use and disclose your personal health information in providing you with treatment and services. We may use or 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 change in your condition to your physician. We also may disclose personal health information to individuals who will be involved in your care when or after you leave the facility. For example: we may disclose personal heath information to a hospital when you are transferred to the hospital.
For 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 payor.For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.
For Health Care Operations. We may use and disclose your personal health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use personal health information to evaluate our facility’s services, including the performance of our staff.
II. WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES
Facility Directory. Unless you object, we will include certain limited information about you in our facility directory. This information may include your name, your location in the facility, and your general condition and your religious affiliation. Our directory does not include specific medical information about you. We may disclose information in our directory, except for your religious affiliation, to people who ask for you by name. For example , we may provide a visitor with your room number. We may provide the directory information including your religious affiliation, to any member of the clergy.
Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your personal health information to a family member or close personal friend, including clergy, who is involved in your care.
Following your death. We may disclose your personal health information after your death to a family member, other relative, close friend or any other person previously identified by you who were involved with your care or payment for your care prior to your death to the extent such disclosure is relevant to such person’s involvement with your care or payment for your care, unless doing so in inconsistent with any prior expressed preferences of yours that is known to us.
Disaster Relief. We may disclose your personal health information to an organization assisting in a disaster relief effort.
As Required By Law. We will disclose your personal health information when required by law to do so.
Public Health Activities. We may disclose your personal health information for public health activities. These activities may include, for example.
Reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting child abuse or neglect:
Reporting to the federal Food and Drug Administration (FDA) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;
To notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition or
For certain purposes involving workplace illness or injuries.
Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your personal health information to notify a government authority if required or authorized by law, or if you agree to the report.
Health Oversight Activities. We may disclose your personal health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government payment or regulatory compliance, and compliance with civil rights laws.
Judicial and Administrative Proceedings. We may disclose your personal health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process, provided we receive certain satisfactory assurances from the party seeking the information or we make reasonable; efforts to contact you about the request or to obtain an order of agreement protecting the information.
Law Enforcement. We may disclose your personal health information for certain law enforcement purposes, including
As required by law to comply with reporting requirements;
To comply with a court order or court ordered warrant, grand jury subpoena, administrative subpoena or summons, investigative demand or similar legal process;
To identify or locate a suspect, fugitive, material witness, or missing person;
When information is requested about the victim of a crime if the individual agrees or under other limited circumstances;
To report the information about a suspicious death;
To provide information about criminal conduct occurring at the facility;
To report information in emergency circumstances about a crime; or
Where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.
Research. We may allow personal health information of residents from our facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your personal health information may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board (comprised of select Board of Director members and others as appropriate) or Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.
Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your personal health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.
To Avert 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 help prevent the threat.
Military and Veterans. If you are a member of the armed forces, we may use and disclose your personal health information as required by military command authorities. We may also use and disclose personal health information about foreign military personnel as required by the appropriate foreign military authority.
Workers’ Compensation . We may use or disclose your personal health information to comply with laws relating to workers’ compensation or similar programs.
National Security and Intelligence Activities: Protective Services for the President and Others. We may disclose personal health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.
Fundraising Activities. We may use certain personal health information to contact you or your designated representative 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 or professional fundraiser so that the foundation or professional fundraiser may contact you in raising money for the facility. In doing so, we would only release the following information: demographic information, including your name, address, contact information, age; gender; and date of birth; the dates you received treatment or services at the facility; department of service information; and outcome information. Any written fundraising material sent by us or on our behalf by a professional fundraiser or related foundation will contain, in a clear and conspicuous manner, a provision indicating how you can elect not to receive any further fundraising communications. We may not condition your treatment on your choice with respect to the receipt of fundraising communications.
Appointment Reminders. We may use or disclose personal health information to remind you about appointments.
Treatment Alternatives. We may use or disclose personal health information to inform you about treatment alternatives that may be of interest to you.
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.
III. EXCEPT FOR USES AND -DISCLOSURES FOR PURPOSES OF TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS AND FOR PURPOSES WHICH ARE REQUIRED BY LAW OR PERMITTED BY LAW, AND DESCRIBED IN THIS NOTICE, WE MAY ONLY USE OR DISCLOSE YOUR PERSONAL HEALTH INFORMATION PURSUANT TO YOUR WRITTEN AUTHORIZATION.
We must obtain your written authorization for the use and disclosure of (a) psychotherapy notes (except to carry out the following limited treatment, payment an health care operations: use by the originator of the notes; use by us for our own mental health training purposes or to defend ourselves in a lawsuit or other type of proceeding brought by you or on your behalf by your personal representative (b) , marketing (except as set forth below)and (c) the sale of protected health information (see below).
You may revoke your authorization to use or disclose personal health information in writing, at any time.
If you revoke your authorization, we will no longer use or disclose your personal health information for the purposes covered by the authorization, except where we have already relied on the authorization.
IV. YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION
You have the following rights regarding your personal health information at the facility:
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you 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, such as a family member or friend, who is involved in your care or in the payment of your care or for notification purposes. For example, you could ask that we not use or disclose information regarding a particular treatment that you received.
We are not required to agree to your requested restriction, except that we are required to comply with the requested restriction if the disclosure is to a health plan for purposes of carrying out payment and health care operations and is not otherwise required by law, and the personal health information pertains solely to a health care item or service for which we have paid in full by you or by someone, other than the health plan, on your behalf.. If we agree to your requested restriction, we will comply with your request unless: (i) the release of the information is needed to provide you emergency treatment and, where such emergency treatment is provided by a health care provider other than us, we will request such other provider not to further use or disclose the information; or (ii) the release of the information is required or otherwise permitted by law.
If you request a restriction, we will need to know the following: (a) what information you want to restrict; (b) whether you want the restriction to apply to our use, to disclosures or both; and (c) whether the restriction will apply to all disclosures or will be limited to certain disclosures (for example, disclosures to a family member).
We may terminate this agreement with regard to a restriction on the use or disclosures of protected health information. We may terminate this agreement with regard to restrictions if (a) you agree to or request the termination in writing, or (b) you orally agree to the termination and the oral agreement is documented or (c) we inform you that we are terminating the agreement, except that we cannot terminate our agreement to a restriction pertaining to disclosures of your health information to a health plan as described above and that such termination is only effective with respect to protected health information created or received after we inform you.
Right of Access to Personal Health Information. You have the right to inspect and/or obtain a copy of your health information that we maintain in a designated record set.. Generally, this includes medical and billing records, but does not include psychotherapy notes, information compiled in reasonable anticipation of or for use in a criminal, civil or administrative action or proceeding or if prohibited by law under the clinical laboratory improvement amendments of 1988. We will provide you with access to your health information in the form and format requested, provided that it is readily producible in such form or format or, if not, in a readable hard copy or such other form and format as agreed to by you and us (see below with respect to electronic records maintained by us).
To the extent that we maintain your personal health information electronically and you request an electronic copy of your health information, we will provide you with access in the electronic form and format requested, provided that it is readily producible in such form or, if not. in a readable electronic form and format that is agreeable to both you and us.
If your request for access directs us to transmit a copy, including an electronic copy, of your health information directly to another individual designated by you, we will provide the copy to the individual designated by you. Your request to transmit a copy of your health information to another individual must be in writing, must be signed by you or your personal representative and must clearly identify the designated individual.
We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to your health information, except in circumstances where the denial is non-reviewable, you may request that the denial be reviewed. Another licensed health care professional selected by our facility will review your request and the denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of this review.
If you request a copy of your information, we may charge a fee for the costs of copying, mailing, if applicable, or other supplies associated with your request.
Right to Request Amendment. You 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. The request for the amendment of personal health information must be in writing and must set for the reason for the request. Wesley Health Care will provide a form for this purpose upon request.
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 our 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 of 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 or certain other exceptions.
Wesley Health Care Center will provide to you, upon request, a form requesting such an accounting. This request will include a time period, which may not be prior to April 13, 2003, and not for a period beyond six years. 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 requests, we may charge you our costs.
Right to a Paper Copy of This Notice. 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.
You may obtain a copy of this Notice at our website www.TheWesleyCommunity.org.
Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.
Marketing. Marketing is a communication about a product or service that encourages the recipient of the communication to purchase or use the product or service. Except where we receive, directly or indirectly, financial remuneration in exchange for making one of the following communications, marketing does not include the following treatment and health care operation communications:
(i) for your treatment, including case management or care coordination, or to direct or recommend alternative treatments, therapies, health care providers or health care settings;
(ii) to describe a health care product or service or the payment for such product or service that is provided by us; or
(iii) for case management and care coordination, contacting you or your personal representative about treatment alternatives and related functions to the extent such communications are not considered treatment.
We must obtain your written authorization in order to use or disclose your health information to make a marketing communication (including those communications set forth at subsections (i), (ii) and (iii) above when we receive financial remuneration, directly or indirectly, in exchange for making such communication), except where the communication is in the form of:
(i) a face-to-face communication made by us to you or your personal representative; or
(ii) a promotional gift of a nominal value provided by us.
Sale of Health Information:
We cannot sell your health information, except pursuant to your written authorization. Certain disclosures are not considered the sale of health information, including but not limited to the following:
(i) for permitted public health purposes;
(ii) for permitted research purposes;
(iii) for treatment and payment purposes;
(iv) for permitted due diligence involving the sale, transfer, merger or consolidation of all or part of our business;
(v) for disclosures to you; or
(vi) for disclosures required by law.
V. NOTIFICATION OF BREACH
In the event we discover or we are notified by one of our business associates that there has been a breach involving your personal health information, we will notify you of the breach without unreasonable delay but in no event later than sixty (60) calendar days after the breach has been discovered, except if we are notified by a law enforcement official that such notification would impede a criminal investigation or cause damage to national security. Unless otherwise required by law, we will notify you in writing by first class mail addressed to your last known address or by electronic mail if you have previously notified us in writing that this is your preferred method of notification. No notice will be provided if the breach involves person health information which is in a secured format.
If you believe that your privacy rights have been violated, you may file a complaint in writing
with the facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the facility, contact the Corporate Compliance Officer. Wesley Health Care Center, Inc. assures that there is no retaliation against a complainant.
VII. CHANGES TO THIS NOTICE
We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all personal health information already received and maintained by the facility as well as for all personal health information we receive in the future. We will post a copy of the current Notice in a prominent location within our facility and on our web site. In addition, we will make the revised or new Notice available upon request to patients, residents and others on or after the effective date of the revision.
VIII. FOR FURTHER INFORMATION
If you have any questions about this Notice or would like further information concerning your privacy rights, please contact the Corporate Compliance Officer at 518-587-3600.
ACKNOWLEDGEMENT OF RECEIPT
Resident Name: ______________________ Date: _____________
I have received a copy of the Privacy Notice. If I have any question pertaining to this notice, or any other subject related to Protected Health Information and the manner in which Wesley Health Care Center protects such information, I will direct it to facility representatives.
Resident or Designated Representative Date
If signed by the resident’s representative, please print name and describe relationship.