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.

We have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this entire notice.

Our Responsibilities

  • Our community is required to:
  • Maintain the privacy of your health information.
  • Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you.
  • Abide by the terms of this notice.
  • Notify you following a breach of unsecured protected health information.

Your Rights

  • As a resident of our community, you have several rights with regard to your health information, including the following:
  • The right to request that we not use or disclose your health information in certain ways.
  • The right to request to receive communications in an alternative manner or location.
  • The right to access and obtain a copy of your health information.
  • The right to request an amendment to your health information.
  • The right to an accounting of disclosures of your health information.

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes on the bulletin board in our community, as well as on our web site. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not use or disclose your health information without your authorization, except as described in this notice. Thus, for example, we will require your authorization before we would use or disclose your protected health information for marketing purposes, and, if applicable, for most uses of psychotherapy notes. In addition, we will not sell your health information without a specific authorization from you.

If have questions and would like additional information, you may contact our community’s Privacy Official.

Understanding Your Health Record/Information

  • Each time you visit a community, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
  • basis for planning your care and treatment;
  • means of communication among the many health professionals who contribute to your care;
  • legal document describing the care you received;
  • means by which you or a third-party payer can verify that services billed were actually provided;
  • a tool in educating health professionals;
  • a source of data for medical research;
  • a source of information for public health officials who oversee the delivery of health care in the United States;
  • a source of data for community planning and marketing; and
  • a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

How We Will Use or Disclose Your Health Information

Treatment

We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from our community.

Payment

We will use or disclose your health information for payment, including for the payment activities of other health care providers or payers. For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health care operations

We will use or disclose your health information for our regular health operations. For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

In addition, we will disclose your health information for certain health care operations of other entities. However, we will only disclose your information under the following conditions:

  • (A) the other entity must have, or have had in the past, a relationship with you;
  • (B) the health information used or disclosed must relate to that other entity’s relationship with you; and
  • (C) the disclosure must only be for one of the following purposes:
    • (i) quality assessment and improvement activities;
    • (ii) population-based activities relating to improving health or reducing health care costs;
    • (iii) case management and care coordination;
    • (iv) conducting training programs;
    • (v) accreditation, licensing, or credentialing activities; or
    • (vi) health care fraud and abuse detection or compliance.

Business associates

There are some services provided in our organization through the use of outside people and entities. Examples of these “business associates” include our accountants, consultants and attorneys. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information, and they are also required to do so by law.

Directory

Unless you notify us that you object, we may use your name, location in the community, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. We may also use your name on a nameplate next to or on your door in order to identify your room, unless you notify us that you object.

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.

Communication with family

We may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health information relevant to that person’s involvement in your care or payment related to your care. If appropriate, these communications may also be made after your death, unless you instructed us not to make such communications.

Research

We may disclose information to researchers when certain conditions have been met.

Transfer of information at death

We may disclose health information to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.

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.

Marketing

We may contact you regarding your treatment, to coordinate your care, or to direct or recommend alternative treatments, therapies, health care providers or settings. In addition, we may contact you to describe a health-related product or service that may be of interest to you, and the payment for such product or service.

Fundraising

We may contact you as part of a fund-raising effort, but you will be provided an opportunity to opt out of these communications.

Food and Drug Administration (FDA)

We may disclose to the FDA, or to a person or entity subject to the jurisdiction of 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.

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.

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.

Correctional institution

Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

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.

Your Health Information Rights

  • Although your health record is the physical property of the community, the information in your health record belongs to you. You have the following rights:
  • You may request that we not use or disclose your health information for a particular reason related to treatment, payment, the community’s general health care operations, and/or to a particular family member, other relative or close personal friend. We ask that such requests be made in writing on a form provided by our community. Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept it or to abide by it, unless it is a request to prohibit disclosures to your health care plan relating to a service for which you have already paid in full out of pocket. We will abide by your requests with regard to the disclosure of your clinical and personal records to anyone outside of the community, except in an emergency, if you are being transferred to another health care institution, or the disclosure is required by law.
  • If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by alternative means or at alternative locations. Such a request must be made in writing, and submitted to ed@gurneeplace.com. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R. § 164.522(b).
  • You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. You may make such requests orally or in writing; however, in order to better respond to your request, we ask that you make such requests in writing on our community’s standard form. If you request to have copies made, we will charge you a reasonable fee. For more information about this right, see 45 C.F.R. § 164.524.
  • If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing and must provide a reason to support the amendment. We ask that you use the form provided by our community to make such requests. For a request form, please contact the Privacy Officer. For more information about this right, see 45 C.F.R. § 164.526.
  • You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed 6 years). We ask that such requests be made in writing on a form provided by our community. Please note that an accounting will not apply to any of the following types of disclosures: 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 made pursuant to a valid authorization; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee. For more information about this right, see 45 C.F.R. § 164.528.
  • You have the right to obtain a paper copy of our Notice of Privacy Practices upon request. You may also access and print a copy of our notice from our website.
  • You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact our community’s Privacy Official at ed@gurneeplace.com.

If you believe that your privacy rights have been violated, you may file a complaint with us. These complaints must be filed in writing on a form provided by our community. The complaint form may be obtained from the executive director at Gurnee Place Memory Care, and when completed should be returned the executive director at Gurnee Place Memory Care. You may also file a complaint with the secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint.

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Signature of Resident Date

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Effective Date