CROWELL MEMORIAL HOME

 

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.

 

I. Our Duty to Safeguard Your Protected Health Information

 

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 on the resident bulletin board on the first floor.  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, you may contact our facility’s Privacy Officer at 402-426-2177, extension 114. 

 

ll. How We May Use and Disclose Your Protected Health Information

 

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 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, 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, therapist, 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/Marketing 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.  We may             also use your photograph in newsletters, facility brochures and etc.  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.  You may contact our         Privacy Officer, Admissions Coordinator or Social Services.  You      must 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, social services or admissions offices.

 

5.         Uses 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.

 

6.         Use and Disclosure Related to Miscellaneous Use:

 

            We may use or disclose your protected health information for directory            purposes; we may also use your name, photograph and a brief bio           description on a bio board outside your room along with any transfer           assistance by use of our ‘star’ system.  We may also use your protected         health information on activity calendars, in Resident Council minutes, on     our bulletin board for which we list new admissions, residents transferred            to the hospital or who have expired.  We may announce your birthday in          the dining room.  We may also request a prayer for you in the event you     are hospitalized or ill. 

 

7.         Use and Disclosure Related to Notification.

 

           

            We may use or disclose information to notify or assist in notifying a family       member, personal representative, or another person responsible for your    care, of your location, and general condition. If we are unable to reach   your family member or personal representative, then we may leave a   message for them at the phone number that they have provided us, e.g.         on an answering machine.  Health professionals, using their best         judgment, may disclose to a family member, other relative, close personal             friend or any other person you identify, health information relevant to that         person’s involvement in your care or payment related to your care.

 

 

lll. Uses and Disclosures Requiring Your Written Authorization

 

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.  You must 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 another individual or                                    facility.

 

lV. Uses or Disclosures of Information Based Upon Your Verbal Agreement

 

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.

 

1.         Information Used or Disclosed in the Facility Directory:

 

            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.  You need to submit this request to the facility       Privacy Officer. 

 

2.         Information Disclosed to Family Members, Friends or Others      Involved in Your Care:

 

            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.  You need to submit this request to the facility Privacy Officer.

 

V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization

 

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:

 

1.         When Required by Law:

 

            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.

 

2.         For Public Health Activities for the Purpose of Preventing or       Controlling Disease, Injury or Disability:

            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 statistic (e.g., births/deaths)       to the public health authority.

 

3.         For Health Oversight Activities:

 

            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.

 

4.         To Coroners, Medical Examiners, Funeral Directors, Organ          Procurement Organizations or Tissue Banks:

 

            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.

 

5.         For Research Purposes:

 

            We may disclose your protected health information for research purposes      only when a privacy board has approved the research project.  However,       we may disclose your protected health information to individuals preparing            to conduct and 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   of this agreement may be obtained from the business office.

 

6.         To Avert a Serious Threat to Health or Safety:

 

            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.

 

7.         For Specific Government Functions:

 

            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.

 

VI. Your Right Regarding Your Protected Health Information

 

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:

 

1.         To Request Restrictions on Uses and Disclosures of Your Protected   Health Information:

 

            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 your 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 must 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.  You must submit this request to       our Privacy Officer.

 

            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.

 

2.         The Right to Inspect and Copy Your Medical and Billing Records:

 

            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.  You must submit your       request 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.

 

3.         The Right to Amend or Correct Your Health Information:

 

            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 amendment/corrections.

 

            We may deny your request if:

           

            a.         Your request is not submitted in writing;

            b.         Your written request does not contain a reason to support your                          request;

            c.         The information was not created by us, unless the person or entity                                that created the information is no longer available to make the                                  amendment;

            d.         It is not a part of the health information kept by or for our facility;

            e.         It is not part of the information which you would be permitted to                          inspect and copy; and/or

            f.          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.

            You must submit your amendment/correction requests on our Request for       Amendment/Correction of Protected Health Information form to our          Privacy Officer.  Copies of these forms are available in the business office.

 

4.         The Right to Request Confidential Communications:

 

            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:

 

            a.         Notify us in writing;

            b.         Indicate what information you wish to limit;

            c.         Indicate whether or not you wish to limit or restrict our use or                              disclosure of such information; and

            d.         Identify to whom the restrictions apply (e.g., which family                                                 member(s), agency, etc).

 

            You must submit your requests on our Request for Restriction of          Confidential Communications form to our Privacy Officer.  Copies of these         forms are available in the business office.

 

5.         The Right to Request an Accounting of Disclosures of Protected          Health Information:

 

            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 release 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 within 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 request       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.

 

            You may submit your requests on our Request for an Accounting of     Disclosures of Protected Health Information form.  Your request must be   submitted to our Privacy Officer.  Copies of these forms are available in     the business office.

 

6.         The Right to Receive a Paper Copy of This Notice:

 

            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).  You may obtain a paper             copy of this notice from our Admissions Coordinator, Social Services             Director or our Privacy Officer.

 

VI. How to File a Complaint About Our Privacy Practices

 

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.

 

You may submit your complaint on our Privacy Practices Complaint form.  You may submit your complaint to our Privacy Officer.  Copies of these forms are available in the business office.

 

 

 

 

Effective date:  April 14, 2003