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 respect the privacy of your personal health information and are committed to maintaining our patients’ confidentiality. This Notice applies to all information and records related to your care that our facility has received or created. It extends to information received or created by our employees, staff, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your personal health information. It also describes your rights and our obligations regarding your personal health information.

We are required by law to:

• maintain the privacy of your protected health information;
  
• provide to you this detailed Notice of our legal duties and privacy practices relating to your personal health information; and
  
• abide by the terms of the Notice that are currently in effect.
  

I. WE MAY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS WITHOUT WRITTEN CONSENT

The law allows us to use and disclose your personal health information for purposes of treatment, payment and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories. At any time, only the minimum necessary protected health information will be released.

For Treatment. We will use and disclose your personal health information in providing you with treatment and services. We may disclose your personal health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, and physical therapists. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose personal health information to individuals who will be involved in your care after you leave the facility.

For Payment. We may use and disclose your personal health information so that we can bill and receive payment for the treatment and services you receive at the facility. For billing and payment purposes, we may disclose your personal health information to your representative, 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 prior approval for a proposed treatment or service.

For Health Care Operations. We may use and disclose your personal health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use personal health information to evaluate our facility’s services, including the performance of our staff.

We may require that you sign a Consent as described above as a condition of our providing treatment to you because the uses and disclosures of your personal health information are essential to our ability to care for you.

II. WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES

Facility Directory. Unless you object in writing, we will include certain limited information about you in our facility directory. This information may include your name, phone number, location in the facility, general condition and your religious affiliation. Our directory does not include specific medical information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.

Individuals Involved in Your Care or Payment for Your Care. Unless you object in writing, we may disclose your personal health information to a family member or close personal friend, including clergy, who is involved in your care. At any time, only the minimum necessary protected health information will be released.

Disaster Relief. We may disclose your personal health information to an organization assisting in a disaster relief effort.

As Required By Law. We will disclose your personal health information when required by law to do so.

Public Health Activities. We may disclose your personal health information for public health activities. These activities may include, for example:

• reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting child/elder abuse or neglect;
  
  
• reporting to the federal Food and Drug Administration (FDA) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;
  
  
• to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition or
  
  
for certain purposes involving workplace illness or injuries.

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 use and disclose your personal health information to notify a government authority if required or authorized by law, or if you agree to the report.

Health Oversight Activities. We may disclose your personal health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. We may disclose your personal 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; efforts must be made to contact you about the request in order to obtain a signed consent or to obtain an order or agreement protecting the information.

Law Enforcement. We may disclose your personal health information for certain law enforcement purposes, including:

• as required by law to comply with reporting requirements;
  
  
• to comply with a court order, warrant, subpoena, summons, investigative demand or similar legal process, a signed consent will be obtained when necessary;
  
  
• to identify or locate a suspect, fugitive, material witness, or missing person;
  
  
• when information is requested about the victim of a crime if the individual agrees or under other limited circumstances;
  
  
• to report information about a suspicious death;
  
  
• to provide information about criminal conduct occurring at the facility;
  
  
• to report information in emergency circumstances about a crime; or
  
  
• where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.
  

Research. We may allow personal health information of patients from our own facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your personal health information may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your personal health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

To Avert a Serious Threat to Health or Safety. We may use and disclose your personal health information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.

Military and Veterans. If you are a member of the armed forces, we may use and disclose your personal health information as required by military command authorities. We may also use and disclose personal health information about foreign military personnel as required by the appropriate foreign military authority.

Workers’ Compensation. We may use or disclose your personal health information to comply with laws relating to workers’ compensation or similar programs.

National Security and Intelligence Activities. We may disclose personal health information to authorized federal officials conducting national security and intelligence activities.

Fundraising Activities. We may use certain personal health information to contact you in an effort to raise money for the facility and its operations. We may disclose personal health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility. In doing so, we would only release contact information, such as your name, address and phone number and the dates you received treatment or services at the facility.

Appointment Reminders. We may use or disclose personal health information to remind you about appointments.

Treatment Alternatives. We may use or disclose personal health information to inform you about treatment alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use or disclose personal health information to inform you about health-related benefits and services that may be of interest to you.

III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF PERSONAL HEALTH INFORMATION

We will use and disclose personal health information (other than as described in this Notice or required by law) only with your written Authorization. You may revoke your Authorization to use or disclose personal health information in writing, at any time. If you revoke your Authorization, we will no longer use or disclose your personal health information for the purposes covered by the Authorization, except where we have already relied on the Authorization.

IV. YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION

You have the following rights regarding your personal health information at the facility:

Right to Request Restrictions. You have the right to request reasonable restrictions on our use or disclosure of your personal health Information for treatment, payment or health care operations. You also have the right to restrict the personal health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.We will make every effort to abide by any request regarding restrictions, however, we must be able to appropriately treat your health needs, bill for services and operate as a facility. Restrictions that impede these functions will be carefully reviewed. If a decision is made to deny your request you have the right to appeal for additional review by contacting the Chief Privacy Officer at Wesbury U.M. Community at 332-9000 or Chief Privacy Officer for Wesbury Hillside Home at 724-3117. Requests for restriction cannot be honored should you require transfer to another facility or are in need of emergency services. Your personal health information is required by law under these circumstances.

Right of Access to Personal Health Information. You have the right to request, either orally or in writing, your medical or billing records or other written information that may be used to make decisions about your care. We must allow you to inspect your records within 24 hours of your request. If you request copies of the records, we must provide you with copies within 2 days of that request. We may charge a reasonable fee for our costs in copying and mailing your requested information.

We may deny your request to inspect or receive copies in certain limited circumstances including information that may be deemed detrimental to the resident’s psychosocial well-being as determined by the attending physician. If you are denied access to personal health information, you will have a right to request review of the denial. This review would be performed by a licensed health care professional designated by the facility who did not participate in the decision to deny.

Right to Request Amendment. You have the right to request to amend by means of an addendum any personal health information maintained by the facility for as long as the information is kept by or for the facility. You must make your request in writing and you must state the reason for the requested amendment.

We may deny your request for amendment if the information:

• was not created by the facility, unless the originator of the information is no longer available to act on your request;
  
  
• is not part of the personal health information maintained by or for the facility;
  
  
• is not part of the information to which you have a right of access; or
  
  
• is already accurate and complete, as determined by the facility.

  If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

  
  Right to an Accounting of Disclosures. You have the right to request an "accounting" of our disclosures of your personal health information. This is a Listing of all disclosures of your personal health information made by the facility or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.

  To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. An accounting will include, if requested: 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; a brief statement of the purpose of the disclosure or a copy of the authorization or request; or certain summary information concerning multiple similar disclosures. The first accounting provided within a 1 2-month period will be free; for further requests, we may charge you our costs.

  Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at anytime. You may obtain a copy of this Notice at our website, www.wesbury.com.

  
  V. COMPLAINTS

  If you believe that your privacy rights have been violated, you may file a complaint in writing with the facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the facility, Chief Privacy Officer at 332-9000 extension 9241 or Chief Privacy Officer at Wesbury Hillside Home at 724-3117.

  Should you feel that the results of your complaint are unsatisfactory resolved you have the right to contact the Office of Civil Rights for further investigation at Health and Human Services Office of Civil Rights 200 Independence Avenue S.W. Washington, D.C. 20201, Phone: 877-696-5775.

  As a community of care, we understand your concerns regarding your privacy and will not regard any action you take as reason for retaliation.

  VI. CHANGES TO THIS NOTICE

  We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all personal health information already received and maintained by the facility as well as for all personal health information we receive in the future. We will post a copy of the current Notice in the facility. In addition, we will provide a copy of the revised Notice to all patients to be distributed. Revisions are also available via our website at www.wesbury.com. If you have any questions or comments regarding this Notice of Privacy Practices please contact our Chief Privacy Officer at extension 9241.

  VII. FOR FURTHER INFORMATION

  If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Chief Privacy Officer at 814-332-9241.