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

	The right to request that we do 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.

	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 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 facility planning and marketing
	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 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

1. 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’re discharged from our nursing facility.

2. 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.

3. 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 care 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.

4. 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’ve asked them to do. To protect your health information, however, w require the business associates to appropriately safeguard your information.

5. Directory. Unless you notify us that you object, we may use your name, location in the facility, 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.

(6) 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.

(7) 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.

(8) Research. We may disclose information to researchers when certain conditions have been met.

(9) 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.

(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 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.

(12) Fund raising. We may contact you as part of a fund-raising effort.

(13) 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.

(14) 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.

(15) 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.

(16) 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.

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

(18) 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 nursing facility, 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 JLR&CS' 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 facility. Although we will consider your request, please be aware that 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).

· 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 Patricia Schlosser, Privacy Officer. 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 facility’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 facility to make such requests. For a request form, please contact the Privacy Office. 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 facility. 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 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:  www.josinalott.org.  

· 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 you have questions and would like additional information, you may contact our facility’s Privacy Officer at (419) 866-9013 or via email at pschlosser@josinalott.org.

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 facility. The complaint form may be obtained from Patricia Schlosser, Privacy Office, and when completed should be returned to her attention. 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 Client / Date

Send mail to cparcell@josinalott.org with questions or comments about this web site.
Last modified: October 18, 2007