THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Please note that we reserve the right to revise our practices with respect to Protected Information
and to amend this notice at any time. Should our practices change, we will post changes at the
facility. In addition, a current notice of our privacy practices may be obtained from the Privacy
Officer at the Daughters of Sarah Senior Community during business hours.
Protected Information - While receiving care from our facility, information regarding your
medical history, treatment, and payment for your health care may be originated and/or received by us. Such
information which can be used to identity you and which relates to your past, present or future medical
condition, to the receipt of health care or to the payment for health care is referred to as “Protected
Our Responsibilities - Federal Law imposes certain obligations and duties upon us as a covered
health care provider with respect to your Protected Information. Specifically, we are required to:
•Provide you with notice of our legal duties and our facility’s policies regarding the use and
disclosure of your Protected Information;
• Maintain the confidentiality of your Protected Information in accordance with state and federal law;
• Honor your requested restrictions regarding the use and disclosure of your Protected Information
unless under the law we are authorized to release your Protected Information without your
authorization, in which case you will be notified of such release within a reasonable period of time;
• Allow you to inspect and copy your Protected Information during our regular business hours;
• Act on your request to amend Protected Information within sixty (60) days and notify you of any
delay which would require us to extend the deadline by the permitted thirty (30) day extension;
• Accommodate reasonable requests to communicate Protected Information by alternative means
or methods: and
• Abide by the terms of this notice.
How Your Protected Information May be Used and Disclosed - Generally, your Protected
Information may be used and disclosed by us only with your express written authorization. However, there
are some exceptions to this general rule.
Treatment, Payment, or Health Care Operations
Treatment Purposes - We may use or disclose your Protected Information for
treatment purposes. During your care at our facility, it may be necessary for various personnel
involved in your care to have access to your Protected Information in order to provide you with
quality care. (For example: nurses or certified nursing assistants.) In addition, we may contact you
to provide appointment reminders or information about treatment alternatives or other health
related benefits and services which may be of interest to you.
Situations may also arise when it is necessary to disclose your Personal Information to
health care providers outside of our facility who may also be involved in your care. (For example: a
home health care agency.)
Payment Purposes - Your Protected Information may also be used or disclosed for
payment purposes. It is necessary for us to use or disclose Protected Information so that treatment
and services provided by us may be billed and collected from you, your insurance company or
other third party payor. It may also be necessary to release Protected Information to obtain prior
approval from your health insurance carrier. We may also release your Protected Information to
another health care provider or individual or entity covered by the HIPAA privacy regulations who
has a relationship with you for their payment activities.
Health Care Operations - Your Protected Information may also be used for health care
operations, which are necessary to ensure that our facility provides the highest quality of care. For
example your Protected Information may be used for quality assurance or risk management
purposes. We may at times remove information which could identify you from your record so as to
prevent others from learning who the specific patients are. In addition, we may release your
Protected Information to another individual or entity covered by the HIPAA privacy regulations that
has a relationship with you for their fraud and abuse detection or compliance purposes, quality
assessment and improvement activities, or review evaluation or training of health care
professionals or students.
Patient Directory - Our facility maintains a patient directory. Unless you object, your
name, location in the facility general condition and religious affiliation will be contained in the
directory. The directory is disclosed to members of the clergy and, except for religious affiliation,
to other persons who specifically ask for the information by your name. You are not obligated,
however, in any way, to consent to the inclusion of your Information in the facility directory. Please
notify facility personnel if you do not wish to be included in the directory or if you wish for
information or disclosure to be limited in some way.
Notification and Communications to Individuals Involved in Your Care - Unless you
have informed us otherwise, your Protected Information may be used or disclosed by us to notify or
assist in notifying a family member or other person responsible for your care. In most cases,
Protected Information disclosed for notification purposes will be limited to your name, location, and
general condition. In addition, unless you have informed us otherwise, Protected Information may
be released to a family member, relative or close personal friend who is involved in your care to the
extent necessary for them to participate in your care. In the event you wish for any of these uses
or disclosures to be limited, please contact facility personnel.
Disaster Relief - We may disclose your Protected Information to any organizations
assisting in disaster relief efforts; however, we will first ask your permission to disclose such
information. If seeking your permission is not feasible, we will disclose the information if, in our
professional judgment, we determine that the disclosure is in your best interests or that you would
not have objected to the disclosure.
Fundraising Activities - We may use your Protected Information for the purpose of
contacting you as part of a fundraising effort. Only demographic information and the dates health
care was provided to you will be used or disclosed in connection with fundraising efforts. If you do
not wish to be contacted for fundraising activities you may contact the Privacy Officer at Daughters
of Sarah Senior Community to have your name removed from our fundraising list.
Research Purposes - In some instances, your Protected Information may be used or
disclosed for research purposes. All research projects which use Protected Information are subject
to a special approval process which will, among other things evaluate the precautions used to
protect Patient medical Information. In many cases, Information which identifies you as the patient
will be removed.
Special Circumstances - Situations may arise which warrant us to use or disclose
Protected Information without your consent or authorization. The law specifically allows us to use or
disclose Protected Information without your consent or authorization in the following special
Public Health Activities - We are allowed to use or disclose your Protected Information for
public health activities and purposes. Examples of public health activities which would
warrant such use or disclosure include:
- Preventing or controlling disease, injury or disability;
- Reporting births or deaths;
- Reporting the abuse or neglect of a child or dependent adult;
- Reporting reactions to medications or problems with products; or
- Notifying individuals exposed to a disease who may be at risk for contracting or
spreading the disease.
Health Oversight Activities - Your Protected Information may be used or disclosed to a
health oversight agency for activities authorized by law. Examples of health oversight
activities include: audits, investigations, inspections, or judicial/administrative proceedings
which you are not the subject of. In most cases, the oversight activity will be for the
purpose of overseeing the care rendered by our facility or our facility’s compliance with
certain laws and regulations.
Judicial and Administrative Proceedings - If you are involved in a lawsuit or other
administrative proceeding, we may release your Protected Information in response to a
court or administrative order requesting the release. In some instances, we may also
release Protected Information pursuant to a subpoena or discovery request, but only if
efforts have been made by the requestor to provide you with notice of the request and you
have failed to object or the objection was resolved in favor of disclosure, or in the
alternative, the requestor has obtained a order protecting the requested information.
Victims of Abuse or Neglect - Other than child and dependent adult abuse, which is
covered under public health activities, we may use or disclose your Protected Information
to a protective services or social services agency or other similar government authority, if
we reasonably believe you have been the victim of abuse, neglect or domestic violence as
long as you agree to such disclosure and we feel it is necessary to prevent serious harm
to you or other individuals. If you are incapacitated and unable to agree to such a
disclosure, we may release your Protected Information for this purpose but only if a failure
to release it would materially and adversely affect a law enforcement activity and the
information will not be used, in any way, against you.
Law Enforcement - We may also release your Protected Information to a law enforcement
officer for the following purposes:
• Pursuant to a court order, warrant, subpoena/summons, or administrative
• Identifying or locating a suspect, fugitive, material witness or missing person;
• Regarding a crime victim, but only if the victim consents or, if the victim is
unable to consent due to incapacity and the information is needed to determine if
a crime has occurred and non disclosure would significantly hinder the
investigation and disclosure is in the victim’s best interests;
• Regarding a decedent, to alert law enforcement that individual’s death was
caused by suspected criminal conduct; or
• By emergency care personnel if the information is necessary to alert law
enforcement of a crime, the location of a crime, or characteristics of the
Coroner, Medical Examiners, Funeral Homes - Protected Information regarding a
decedent may be released to a coroner or medical examiner for the purpose of identifying
a deceased person, determining cause of death or other duties as authorized by law.
Protected Information regarding a decedent may also be disclosed to funeral directors if
necessary to carry out their duties.
Specialized Government Functions - Your Protected Information may be used or
disclosed for a variety of government functions subject to some limitations. These
government functions include:
• Military and veterans activities;
• National security and intelligence activities;
• Protective service of the President and others;
• Medical suitability determinations for Department of State officials;
• Correctional institutions and law enforcement custodial situations; or
• Provision of public benefits
Organ Donation - Your Protected Information may be used or disclosed by us to entities
engaged in the procurement, banking or transplantation of organs, eyes, or tissues for the
purpose of facilitating such donations and transplantation.
Workers Compensation - We are allowed to disclose your Protected Information as
authorized and to the extent necessary to comply with laws relating to workers’
compensation or other programs providing benefits for work-related injuries or illness
without regard to fault.
More Stringent Laws - Some of your Protected Information may be subject to other laws
and regulations and afforded greater protection than what is outlined in this Notice. For
instance, HIV/AIDS, substance abuse, and mental health information are often given more
protection. In the event that your Protected Information is afforded greater protection
under Federal or State law, we will comply with the applicable law.
Your Rights - Federal law grants you certain rights with respect to your Protected Information.
Specifically, you have the light to:
•Receive notice of our policies and procedures used to protect your Protected
• Request that certain uses and disclosures of your Protected Information be restricted;
provided that, however, if we may otherwise release the information without your consent
or authorization we have the right to refuse your request;
• Access to your Protected Information; provided, however, that the request must be in
writing and may be denied in certain limited situations;
• Request that your Protected Information be amended;
• Obtain an accounting of certain disclosures by us of your Protected Information for the
past six years,
• Revoke any prior authorizations or consents for use or disclosure of Protected
Information, except to the extent that action has already been taken; and
• Request that communications of your Protected Information are done by alternative
means or at alternative locations.
Important Contact Information - This notice has been provided to you as a summary of how we
will use your Protected Information and your rights with respect to your Protected Information. If
you have any questions or for more Information regarding your Protected Information, please
contact the Privacy Officer at Daughters of Sarah Senior Community.
If you believe that your privacy rights have been violated, you may file a complaint with us
by contacting the Privacy Officer at the Daughters of Sarah Senior Community. You may
also file a complaint with the Secretary of Health and Human Services. There will be no
retaliation for the filing at a complaint.
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