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Church Homes, Inc. [ d/b/a Noble Horizons ] ("the Facility") NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW
MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please call Ray Gasperini The effective date of this privacy notice is April 14, 2003 At the Facility, we respect
the privacy and confidentiality of your health information. This Notice of Privacy Practices ("Notice")
describes how we may use and disclose your medical/health information and how
you can get access to this information.
This Notice applies to uses and disclosures we may make of all your health
information whether created or received by us. I. OUR
RESPONSIBILITIES TO YOU We are required by law to: 1. Maintain
the privacy of your health information and to provide you with notice of our
legal duties and privacy practices. 2. Comply with the
terms of our Notice currently in effect. We reserve the right to change our practices and to
make the new provisions effective for all health information we maintain,
including both health information we already have and health information we
create or receive in the future.
Should we make material changes, we will make the revised Notice
available to you by posting it in a clear and prominent location. II. HOW
WE WILL USE AND DISCLOSURE YOUR HEALTH INFORMATION FOR TREATMENT, PAYMENT AND
HEALTH CARE OPERATIONS We
may use and disclose your health information for purposes of treatment, payment
and health care operations as described below. 1. For
Treatment. We may use and disclose your health
information to provide you with treatment and services and to coordinate your
continuing care. Your health
information may be used by doctors and nurses, as well as by lab technicians,
dieticians, physical therapists or other personnel involved in your care, both
within our Facility and by other health care providers involved in your care.
For example, a pharmacist will need certain information to fill a prescription
ordered by your doctor. We may
also disclose your health information to persons or facilities that will be
involved in your care after you leave our Facility. 2. For Payment. We may
use and disclose your health information so that we can bill and receive
payment for the treatment and services you receive. For billing and payment purposes, we may disclose your
health information to an 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 approval for a proposed treatment or service. 3. For Health
Care Operations. We may use and disclose your health
information as necessary for our internal operations, such as for general
administration activities and to monitor the quality of care you receive with
us. For example, we may use your
health information to evaluate and improve the quality of care you received,
for education and training purposes, and for planning for services. III. OTHER
USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR WRITTEN AUTHORIZATION Under
the Privacy Regulations, we may make the following uses and disclosures without
obtaining a written Authorization from you: 1. As Required
By Law. We may disclose your health information when required by law
to do so. 2. Facility
Directory. Unless you object, we may use and
disclose certain limited information about you in our Directory while you are a
patient. This information may
include your name, your location in the Facility, your general condition and
your religious affiliation. Our
Directory does not include specific medical information about you. We may disclose Directory information,
except for your religious affiliation, to people who ask for you by name. We may provide the Directory
information, including your religious affiliation, to a member of the clergy. 3. Persons
Involved in Your Care or Payment for Your Care. Unless
you object, we may disclose health information about you to a family member,
close personal friend or other persons you identify, including clergy, who are
involved in your care. These
disclosures are limited to information relevant to the person’s
involvement in your care or in arranging payment for your care. 4. Public
Health Activities. We may disclose your health information
for public health activities. 5. 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 disclose your health information to notify a government authority, if
authorized by law or if you agree to the report. 6. Health
Oversight Activities. We may disclose your health information
to a health oversight agency for activities authorized by law. A health oversight agency is a state or
federal agency that oversees the health care system. Some of the activities may include, for example, audits,
investigations, inspections and licensure actions. 7. Judicial
and Administrative Proceedings. We may disclose your 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. 8. Law
Enforcement. We may disclose your health information
for certain law enforcement purposes, including, for example, to file reports
required by law or to report emergencies or suspicious deaths; to comply with a
court order, warrant, or other legal process; to identify or locate a suspect
or missing person; or to answer certain requests for information concerning
crimes. 9. Coroners,
Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may
release your health information to a coroner, medical examiner, and funeral
director and, if you are an organ donor, to an organization involved in the
donation of organs and tissue. 10. Research. Your
health information may be used for research purposes, but only if: (1) the
privacy aspects of the research have been reviewed and approved by a special
Privacy Board or Institutional Review Board and the Board can legally waive
patient authorizations otherwise required by the Privacy Regulations; (2) the
researcher is collecting information for a research proposal; (3) the research
occurs after your death; or (4) if you give written authorization for the use
or disclosure. 11. To Avert a
Serious Threat to Health or Safety. When necessary to prevent a serious
threat to your health or safety, or the health or safety of the public or
another person, we may use or disclose your health information to someone able
to help lessen or prevent the threatened harm. 12. Military and
Veterans. If you are a member of the armed
forces, we may use and disclose your health information as required by military
command authorities. We may also
use and disclose health information about you if you are a member of a foreign
military as required by the appropriate foreign military authority. 13. National Security
and Intelligence Activities; Protective Services for the Patient and Others. We may
disclose 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. 14. Inmates/Law
Enforcement Custody. If you are an inmate of a correctional
institution or under the custody of a law enforcement official, we may disclose
your health information to the institution or official for certain purposes
including your own health and safety as well as that of others. 15. Workers'
Compensation. We may use or disclose your health
information to comply with laws relating to workers' compensation or similar
programs. 16. Disaster Relief. We may
disclose health information about you to an organization assisting in a
disaster relief effort. 17. Fundraising
Activities. We may use limited health information
such as your name, address and phone number and the dates you received
treatment or services, to contact you in an effort to raise money for the
Facility. We may also disclose
contact information for fundraising purposes to a foundation or auxiliary
related to the Facility. 18. Treatment
Alternatives and Health-Related Benefits and Services. We may
use or disclose your health information to inform you about treatment
alternatives and health-related benefits and services that may be of interest
to you. 19. Business
Associates. We may disclose your health information
to our business associates under a Business Associate Agreement. IV. YOUR
WRITTEN AUTHORIZATION IS REQUIRED FOR ALL OTHER USES OR DISCLOSURES OF YOUR
HEALTH INFORMATION 1. We will obtain your written authorization (an
"Authorization") prior to making any use or disclosure other than
those described above. 2.
A written
Authorization is designed to inform you of a specific use or disclosure, other
than those set forth above, that we plan to make of your health
information. The Authorization
describes the particular health information to be used or disclosed and the
purpose of the use or disclosure.
Where applicable, the written Authorization will also specify the name
of the person to whom we are disclosing the health information. The Authorization will also contain an
expiration date or event. 3. You may revoke a written Authorization previously given by you at any time but you must do so in writing. If you revoke your Authorization, we will no longer use or disclose your health information for the purposes specified in that Authorization except where we have already taken actions in reliance on your Authorization. V. YOUR
RIGHTS REGARDING YOUR HEALTH INFORMATION You
have the following rights regarding your health information: 1. Right to
Request Restrictions. You have the right to request that we
restrict the way we use or disclose your health information for treatment,
payment or health care operations.
However, we are not required to agree to the restriction. If we do agree to a restriction, we
will honor that restriction except in the event of an emergency and will only
disclose the restricted information to the extent necessary for your treatment.
2. Right to
Request Confidential Communications. You have the right to request that we
communicate with you concerning your 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. 3. Right of
Access to Personal Health Information. You have the right to
inspect and, upon written request, obtain a copy of your health
information. Under Connecticut
law, if the Facility makes a copy of your medical record, we will not charge
more than $.65 per page, plus postage, plus a reasonable fee if you want x-ray
films or tissue samples. 4. Right to
Request Amendment. You have the right to request that we
amend your health information.
Your request must be made in writing and must state the reason for the
requested amendment. We may deny
your request for amendment if the information: (a) was not created by us,
unless you provide reasonable information that the originator of the
information is no longer available to act on your request; (b) is not part of
the health information maintained by us; or (c) is already accurate and
complete, as determined by us. If
we deny your request for amendment, we will give you a written denial notice,
including the reasons for the denial.
In that event, you have the right to submit a written statement
disagreeing with the denial. Your
letter of disagreement will be attached to your medical record. 5. Right to an
Accounting of Disclosures. You have the right to request an
“accounting” of certain disclosures of your health information. This is a listing of disclosures made
by us or by others on our behalf, but does not include disclosures for
treatment, payment and health care operations or certain other exceptions. You
must submit your request in writing and you must state the time period for
which you would like the accounting.
The accounting will include 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; and a brief statement of the purpose
of the disclosure. The first
accounting provided within a 12-month period will be free; for further
requests, we may charge you our costs for completing the accounting. VI. SPECIAL
REGULATIONS REGARDING DISCLOSURE OF PSYCHIATRIC AND HIV-RELATED INFORMATION For
disclosures concerning certain health information such as HIV-related
information or records regarding psychiatric care that have been sent to us by
another provider, special restriction apply. Generally, we will disclose such information only with an
Authorization, or as otherwise required by law. VII. COMPLAINTS 1. If you believe
that your privacy rights have been violated, you may file a complaint in
writing with us or with the Office of Civil Rights Region 1, US Department of
Health and Human Services, JFK Federal Building Room 1875, Governmental Center,
Boston, MA 02203. 2. To file a
complaint with us, you should contact: Raymond A. Gasperini Church Homes, Inc. 217 Avery Heights Hartford, CT 06106 860-527-9126, ext. 360 3. We
will not retaliate against you in any way for filing a complaint against the Facility. |