HIPAA Privacy Notice

WESTMINSTER VILLAGE NORTH, INC.

Notice of Privacy Practices

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.

Westminster Village North respects the privacy of your personal health information and is committed to maintaining our residents’ 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, 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. USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

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 therapists. 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, insurance or managed care company, Medicare, Medicaid or another third party payer.

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.

II. SPECIFIC USE AND DISCLOSURES OF PERSONAL HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES

Facility Reports. Unless you object, we will include certain limited information about you in our facility reports. This information may include your name, your location in the facility, and payer type. Our reports may include specific medical information about you. We may release information in our reports to people who ask for you by name.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your personal health information to a family member or close personal friend, including clergy, who is involved in your care. Other purposes for which we may disclose Protective Health Information are as follows:

• Disaster Relief
• Public Health Activities
• Reporting Victims of Abuse, Neglect or Domestic Violence
• Health Oversight Activities (i.e. Indiana Department of Health)
• Judicial and Administrative Proceedings
• Law Enforcement
• Research
• Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations
• To Avert a Serious Threat to Health or Safety
• Military and Veterans
• Workers’ Compensation
• Fundraising Activities
• Appointment Reminders
• Treatment Alternatives and Health Related Benefits
• Health-Related Benefits and Services
• Emergencies
• As Otherwise Required By Law

III. AUTHORIZATION REQUIRED FOR OTHER USES OF PERSONAL HEALTH INFORMATION

No other use or disclosure of your personal health information (other than as described in this Notice or required by law) will be released without 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 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 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 [all requests must be submitted in writing].

We are required to agree to your requested restriction unless you are being transferred to another health care institution, the release of records is required by law, or the release of information is needed to provide you with emergency care.

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 make a “demand request” for copies of the records, we must provide you with copies within 2 business days of that request. We may charge a reasonable fee for our costs in copying and mailing your requested information. [forms are available to make this request to access].

Right to Request Amendment. You have the right to request the facility to amend 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 must state the reason for the requested amendment. [forms are available for this request to amend].

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 certain 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. [forms are available for this request to obtain an accounting].

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice. You may request a copy of this Notice at any time. [You may obtain a copy of this Notice at our website, www.westminstervillage.com].

Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. We will accommodate your reasonable requests.

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, contact the Health Center Administrator or the HIPAA Compliance Manager at extension 357/or 218.

VI. CHANGES TO 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 upon request.

VII. FOR FURTHER INFORMATION

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact the Admission offices at extension 293/or 284 or the HIPAA Compliance Manager at extension 218.

Privacy Notice V.1