NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed. It also includes how you can get access to this information. Please review it carefully.
Your medical information is the information gathered by your healthcare providers during the time you are living at Grand Villa Senior Living, (“the Community”). It is private, and no one without a legitimate need to know may have access to it. The Community is required by law to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. The Community will promptly notify affected individuals following a breach of unsecured protected health information. The Community will not use or disclose your health information except as described in this Notice of Privacy Practices (“Notice”). This Notice applies to all of the medical records generated or obtained during your stay in the Community.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
The following categories describe the ways that the Community may use and disclose your health information without a specific authorization from you:
Treatment: The Community will use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued
treatment of the individual.
Payment: The Community may release medical information about you for the purposes of determining coverage, billing, claims management, medical data processing and reimbursement. The information may be released to an insurance company, third-party payor or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record that are necessary for payment of your account. For example, a bill sent to a third party payor may include information that identifies you, your diagnosis, the procedures and supplies used.
Routine Healthcare Operations: The Community may use and disclose your medical information during routine healthcare operations, including quality assurance, utilization review, internal auditing, accreditation, certification, licensing or credentialing activities, medical research and educational purposes.
Business Associates: The Community may use and disclose certain medical information about you to its business associates. A business associate is an individual or entity under contract with the Community to perform or assist the Community in a function or activity that necessitates the use or disclosure of medical information. Examples of business associates include but are not limited to, a copy service used by the Community to copy
medical records, consultants, independent contractors, accountants, lawyers, medical transcriptionists, electronic medical record providers, software providers and third-party billing companies. The Community requires the business associate to protect the confidentiality of your medical information. In addition, the Community requires any subcontractor of the Community’s business associate to protect the confidentiality of your medical information.
Required by Law: The Community will disclose medical information about you when required to do so by law.
Public Health Activities: The Community may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
Victims of Abuse, Neglect or Domestic Violence: The Community may disclose your health information to a public health authority that is authorized to receive reports of abuse, neglect, or domestic violence. We may make an effort to obtain your permission before releasing this information, but in some cases may be required or authorized to act without your permission.
Health Oversight, Licensing, Accreditation and Regulatory Activities: The Community may disclose your health information to health oversight agencies authorized to conduct audits, investigations, and inspections of our community. For example, billing practices may be audited by the State Auditor and records are subject to review by the Secretary of Health and Human Services and his/her authorized representatives.
Judicial or Administrative Proceedings: The Community may disclose your health information if we are ordered to do so by a court or an administrative hearing officer that is handling a lawsuit or other dispute or provided with a valid subpoena.
Disclosures for Law Enforcement Purposes: The Community may disclose your identity to law enforcement. Instances which may result in a disclosure of protected health information to law enforcement include to comply with court orders or assist with ongoing investigations.
Coroners, Medical Examiners and Funeral Directors: The Community may disclose protected health information to a coroner, medical examiner or funeral director for the purposes of identifying a deceased person or other duties as authorized by the law.
Organ and Tissue Donation: The Community may share health information about you with organ procurement organizations.
Research: In some instances, the Community can use or share your health information for health research.
To Avert a Serious and Imminent Threat to Health or Safety: The Community may use or disclose your protected health information when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety or another person or the public.
Specialized Government Functions: The Community may disclose your medical information to authorized federal officials for military and veteran activities.
Workers’ Compensation: The Community may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
INDIVIDUAL CHOICES
You have the right and choice to tell us which information to share with your family, close friends, or others involved in your care, and if you would like us to share your information in a disaster relief situation.
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In the case of fundraising, the Community may contact you for fundraising efforts, but you can tell us not to contact you again.
Except for the situations and exceptions described in this Notice, we will need to obtain your written authorization before using or disclosing your protected health information for other purposes. For example, except as otherwise set forth under State and Federal law, we must obtain your written authorization for most uses or disclosures of any psychotherapy notes related to you, for the use or disclosure of your protected health information for marketing purposes, or for the sale of your protected health information.
INDIVIDUAL INFORMATION RIGHTS
Although all records concerning your treatment obtained at the Community are the property of the Community, you have the following rights concerning your medical information:
Right to Confidential Communications: You have the right to receive confidential communications of your medical information by alternative means or at alternative locations. For example, you may request that the Community contact you only at work or by mail.
Right to Inspect and Copy: You have the right to inspect and copy your medical information upon receipt of a written request. Copies will be provided within 30 days.
Right to Amend: You have the right to amend your medical information. Any request for amendment should be submitted to the Community in writing, stating a reason in support of the amendment. Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.
Right to Request Restrictions: You have the right to request restrictions in writing on certain uses and disclosures of your medical information. The Community is not required to honor your request unless: (i) the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid the Community in full.
Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice, even if you have previously agreed to receive the Notice electronically.
Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information upon receipt of a written request. Copies will be provided within 30 days.
Right to Transfer Records: You may also initiate the transfer of your records to another person by completing a written authorization form.
Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to the Community. Forms to help you make your request are available at the Community, or by contacting the Community.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact the Community or our HIPAA Privacy Officer at (727) 726-3980. If you believe your privacy rights have been violated, you may file a complaint with the Community or with the Secretary of the Department of Health and Human Services. To file a complaint with the Community, please contact the front desk located near the front entrance to the community. All complaints must be submitted in writing. Forms are available upon request. There will be no retaliation for filing a complaint.
CHANGES TO THIS NOTICE
The Community will abide by the terms of the Notice currently in effect. The Community reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. An updated version of the Notice may be obtained at the Community and on our web site.
NOTICE EFFECTIVE DATE
This Notice is effective as of July 2016
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I certify that I have received a copy of the Community’s Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my care, payment of my bills or in the performance of the Community’s care operations. The Notice of Privacy Practices also describes my rights and the Community’s duties with respect to my protected health information. The Notice of Privacy Practices is also posted in the Community and is available on the Community’s website.
The Community reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the Community and requesting a revised copy be sent in the mail, asking for one at the Community, or accessing the website.
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Resident Signature Date
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Responsible Party Signature Date
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