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.
Understanding Your Health Records and Information and its Use
You, as a resident in this facility, have a medical record kept on your treatment and your condition. This medical record contains symptoms, diagnosis and treatments the facility provided. It also may have test results and the plan for your care. Information like this in your record is "protected health information", which we will refer to as "your information" or "your health information". We have to treat your information in a certain way as outlined by the law. "You" in this document means you or your legal representative, and "we" means the facility or its representative.
Our facility must follow this notice until we change its terms. We may change the terms of this notice at any time. If we do change it, we will send you a new notice with the changes. Our facility must protect the privacy of your health information.
How We May Use Your Information
Treatment: We will use your information to treat you. For example, we may use your information to determine how best to provide care to you. Our staff may use your information to talk with your doctor and notify him of your condition.
Payment: We will use your information to receive payment for our services. For example, we may send information about you to make a claim to Medicare, Medicaid or private insurance.
Health Care Operations: We may use your information for activities that are necessary to run our facility and to support the core functions of treatment and payment. For example, a group of our clinical staff, called our quality improvement team, may use your information to look at the care we are providing to you and other residents and seek to improve that care by discussing your case.
We may also give your information to companies or other consultants to help us do our job of taking care of you, like lawyers or billing companies. However, if we do that, we will make that contractor protect your information just as we must protect it.
Directory: Unless you tell us not to, we can use your information for a facility directory. If someone asks about you, we can tell him or her your name, where you are in the facility and generally what your condition is. We can also tell members of the clergy what your religious affiliation is if they ask.
Fundraising / Marketing: We will not use information in your records for marketing purposes without your approval and written consent of such disclosure. We may use your information to contact you about fundraising for the facility, or to have a Business Associate of our organization contact you. Other uses and disclosures from your medical record will be made only with your written authorization or approval.
To Government Agencies: Numerous state and federal laws require the facility to provide certain people with access to your information. For example, the facility must allow state and federal inspectors, called surveyors, to look at resident's medical records to evaluate the services the facility is providing. We may also have to disclose your information for national security purposes, or as required by military authorities if you are in the military.
To Others Involved In Your Care: We may use your information to help us tell someone involved in your care about your condition and treatment. Those people may include a family member, your personal representative, friend, or other person. If we cannot reach them, we may leave them a message at a number they have provided to us. Our staff may also use their best judgment to disclose information important to your care to one of those people, but only if that information is needed to help them inform us of how to care for you.
Business Associates: We may disclose your information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified herein.
Research: We may use your information to do research for our facility or organization. If we do so, certain privacy protections have to be in place before we can disclose your information.
Public Health / Public Health Risks:We may provide your information to public health agencies for public health activities of the government. These activities include disclosures to prevent or control disease, injury, disability, deaths, medication errors and/or reactions, medication problems with products, recall of products, and persons who may be at risk for contracting or spreading a disease or condition as required by law.
As Required By Law: We can disclose your information if it is necessary for us to comply with legal proceedings, such as a court order, search warrant or subpoena.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose information in response to a court or administrative order. We may also disclose information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; 6) in an emergency to report a crime, the location of the crime or victims, or the identity; and 7) in the event of a natural disaster, or other disaster out of our control.
National Security and Intelligence Activities: We may release information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
Abuse, Neglect, Crime Reporting or Serious Threat: We may release your information to individuals when we believe a resident may be the victim of abuse or neglect. We may disclose your information to report or follow up on a crime. We may also release your information to avoid a serious threat to the health or safety or your or others.
Workers' Compensation: We may release information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Coroners or Funeral Directors: We may tell coroners or funeral directors about a deceased person's health information.
Data Breach Notification Purposes: We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
Written Authorizations: If you give us your written authorization to give your information to someone or to use it in a particular way, we may do so. However, we will ask for that authorization prior to using or giving out your information. You can change your mind about the authorization at any time if you tell us in writing.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES.
Your Rights: You may make a written request that the facility do one or more of the following things relative to your health information.
Inspect and Copy: Your physical medical record belongs to the facility. However, you may look at your records and request a copy of your information. You must make your request in writing to us, and we will respond to your request in a reasonable time. We may charge a fee to give you a copy of your information as permitted by law. We may also refuse your request in limited circumstances as the law allows.
Right to an Electronic Copy of Electronic Medical Records: If your information is maintained in an electronic format (known as electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your information in the form or format you request, if it is readily producible in such form or format. If the information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We charge you a reasonable, cost-based fee for the materials and labor associated with transmitting the electronic medical record or hard copy production.
Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured health information.
Additional Restrictions: You may request that the facility put additional restrictions on the use of your health information. You must do so in writing. While we will consider your request, we do not have to agree to your request.
Out-of-Pocket Payments: If you have paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your information with respect to that item or service not be disclosed to a health plan for purposes of payment of the health related treatment and health care operation.
Alternate Location or Means: You can ask the facility to communicate with you or your legal representative either in a different fashion or at a different location than you receive notices now. We will honor reasonable requests, so long as they are in writing.
Amend Information: If you think any information is missing or is incorrect in your record, you can ask the facility to correct your information or add information. We ask you to do this in writing and explain why you think we should change your record. In some cases, we may not agree to your request.
Written Accounting: You may ask us for a list of disclosures of your medical information during a certain time. That time period cannot be more than six (6) years. Any list of disclosures will not include disclosures made for treatment, payment or health care operations; disclosures to you or anyone involved in your care or disclosures to law enforcement officials or national security. We will not charge you for your first request in any twelve (12) month period. After that, we will charge you a fee.
Notice: You have a right to get this notice in a paper copy if you ask for it.
Authorizations: You have the right to revoke any authorization to use your information, except if we have already acted on that permission.
Complaints: If you think your privacy rights have not been followed or have been violated, you may file a complaint with us. The information on where to complain to is listed below. You may also file a complaint with the Department of Health and Human Services, a federal agency. We cannot and will not take any action against you for filing a complaint.
Executive Director, Privacy Officer
55 Nursing Home Road
Chuckey, Tennessee 37641
This revised notice is effective on September 17, 2013.