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 have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this
entire notice. Our Responsibilities Our facilities are required to:
Your Rights
We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our
privacy practices change, we will post the changes on the bulletin board in our facility, as well as on our web site. A copy of the revised notice will
be available after the effective date of the changes upon request.
We will not use or disclose your health information without your authorization, except as described in this notice. Thus, for example, we will
require your authorization before we would use or disclose your protected health information for marketing purposes, and, we will not sell your
health information without a specific authorization from you.
If you have questions and would like additional information, you may contact our facility’s Corporate Compliance Officer at Willow Brook Christian
Communities, ATTN: Corporate Compliance Officer, 100 Delaware Xing W, Delaware, OH 43015.
Understanding Your Health Record/Information
Each time you visit a nursing facility; a record of your visit is made. Typically, this record contains your symptoms, examination and test results,
diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
Understanding what is in your record and how your health information is used helps you to: ensure its 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 are 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 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 © 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) (5) (6) (7) (8) (9) (10)
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 have asked them to do. To protect your health information, however, we require the business associates to
appropriately safeguard your information, and they are also required to do so by law.
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. If appropriate, these
communications may also be made after your death, unless you instructed us not to make such communications.
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)
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) (13) (14) (15) (16) (17) (18)
12. Fundraising. We may contact you as part of a fund-raising effort, but you will be provided an opportunity to opt out of these communications.
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:
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 Willow Brook Christian Communities, ATTN: Corporate Compliance Officer, 100 Delaware Xing W, Delaware, OH
43015. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R. section 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
C.F.R. section 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 Officer. For more information about this right, see 45 C.F.R. section 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 made pursuant to a valid authorization; 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. section 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.
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.
ForMore Information or to Report a Problem If you have questions and would like additional information, you may contact our facility’s Corporate
Compliance Officer at Willow Brook Christian Communities, ATTN: Corporate Compliance Officer, 100 Delaware Xing W, Delaware, OH 43015.
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 Willow Brook Christian Communities, ATTN: Corporate Compliance Officer, 100
Delaware Xing W, Delaware, OH 43015, and when completed should be returned to Willow Brook Christian Communities, ATTN: Corporate
Compliance Officer, 100 Delaware Xing W, Delaware, OH 43015. 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.
Effective Date: September 23, 2013
