Rosewood Care Center, Inc. of __________
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Legal Duty
State and federal law to require Rosewood Care Center, Inc. of ___________ to:
· maintain the privacy of your health information
· provide you with this notice about our legal duties and privacy practices and your legal rights pertaining to health information we collect and maintain about you
· follow the privacy practices described in this notice while it is in effect
· notify you if we are unable to agree to a requested restriction pertaining to your health information
· accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.
We reserve the right to change our information practices and to make the changes effective for all protected health information we maintain. Should our information practices change, we will change our Notice of Privacy Practices and make the new Notice available to you.
How We Will Use or Disclose Your Health Information
We use and disclose health information about you for treatment, to obtain payment for healthcare operations and for other purposes. For example:
(1) Treatment. We may disclose health information about you to physicians, hospitals, medical technicians or other healthcare providers who are or who may be providing treatment to you.
(2) Payment. We may use and disclose your health information to obtain payment for services we provide to you.
(3) Healthcare operations. We may use and disclose your health information in
connection with our healthcare operations including quality assessment and
improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, investigating claims, conducting training programs, accreditation, certification, licensing or credentialing activities.
(4) Business associates. We may disclose your health information to our business associates so that they can perform services for us. To protect your health information, we require our business associates to keep your information confidential.
(5) Directory. Unless you notify us that you object, we may use your name, location in the facility and general condition for directory purposes. This information may be provided to people who ask for you by name. We may also use your name on a facility directory, name plate next to or on your door in order to identify your room, unless you notify us that you object.
(6) Notification of Persons Involved in Care. 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 or on an answering machine.
(7) Communication with family. We may disclose to a family member, relative, 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.
(8) Research. We may disclose 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 health information.
(9) Funeral directors. We may disclose health information to funeral directors and coroners to carry out their duties.
(10) Organ procurement organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
(11) Marketing. We may use your health information to inform you about treatment alternatives or other health?related benefits and services that may be of interest to you. We will not disclose your health information to others for the purpose of marketing.
(12) Food and Drug Administration (FDA). We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
(13) Workers compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
(14) Public health. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
(15) Law enforcement. We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
(16) Reports. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
(17) Required by Law. We may use or disclose your health information as may be required by law.
(18) National Security. We may disclose your health information to federal and state officials as may be required for national security activities.
Your Health Information Rights
Although your health record is the property of Rosewood Care Center, Inc. of ___________ You have the following rights:
o Inspection and Copying. You may look at and obtain copies of health information about you (with limited exceptions). Requests to view or to obtain copies of your health information must be in writing, signed by you or your authorized representative. If you request copies, we will charge you a reasonable copying and administrative fee according to law. For more information about this right, see 45 C.F.R. § 164.524.
o Restriction. You may request additional restrictions on the use and disclosure of health information about you. Although we will consider your request, we are under no obligation to accept it or to abide by it. For more information about this right, see 45 Code of Federal Regulations (C.F.R.) § 164.522(a).
o Alternative Communication. You may request that we communicate with you about your health information by alternative means or at alternative locations. Such a request must be made in writing, and submitted to the privacy officer. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R. § 164.522(b).
o Amendments. You may request that we amend or make additions to your health information. Such requests must be made in writing, and must explain the reason for requesting the amendment or addition. We may deny your request under certain circumstances. For more information about this right, see 45 C.F.R. § 164.526.
o Disclosure Accounting. You may request that we provide you with a written statement of all disclosures of your health information made by us during a time period not exceeding 6 years immediately prior to your request and not for disclosures before April 14, 2003. Such an accounting does not apply to disclosures made for reasons of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You may obtain this accounting at no charge once in a twelve month period but you will be charged a reasonable fee for complying with additional requests in any twelve month period. For more information about this right, see 45 C.F.R. § 164.528.
o Copy of Notice of Privacy Practices. This Notice of Privacy Practices is posted at Rosewood Care Center, Inc. of ___________ and it is on our website: "RosewoodNursing.com" and you have the right to obtain a paper copy of our Notice of Privacy Practices.
o Revocation of Authorization. You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken in reliance on your authorization. Such a revocation must be in writing signed by you or your authorized representative.
For More Information or to Report a Problem
If have questions and would like additional information, you may contact our Organization's Privacy Officer at Midwest Administrative Services, Inc., 11701 Borman Drive, Suite 315, St. Louis, Missouri, 63146; Telephone: 314 994 9070.
If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing should be sent to the Privacy Officer at the above address. You may also file a complaint with the Secretary of the United States Department of Health and Human Services. There will be no retaliation for filing a complaint.
Effective Date: April 14, 2003.
Rosewood Care Center of St. Louis County, Inc
Acknowledgement of Receipt of Notice of Privacy Practices:
I received a copy of Notice of Privacy Practices from Rosewood Care Center, Inc. of ___________.
______________________________
Print name
_______________________________ ______________
Signature Date
You may refuse to sign this form.
For Office Use Only
On _______________Rosewood Care Center, Inc. of ___________ attempted to obtain written acknowledgement of receipt of Notice of Privacy Practices. A copy of the foregoing was given to Resident or Resident's Representative, _______________________________ , but written acknowledgement could not be obtained because: (print name)
q Resident/Representative refused to sign
q Communication with resident was impossible
q Other (please describe)
____________________________________ _________________
Print Name Title
____________________________________ __________________
Signature Date