NOTICE OF PRIVACY RULES
Legacy Lodge Assisted Living
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.
I. Understanding Your Protected Health Information
When you are admitted to the Facility, a health record of your visit is made containing your billing information, physical examination, test results, diagnoses, and treatment plan for future care. This is called information protected health information (PHI).
II. Our Responsibilities
The Health Insurance Portability & Accountability Act (HIPAA) Law requires our Facility to maintain the privacy of your health information, provide this Notice of Privacy Practices (called Notice) of our legal duties and privacy practices with respect to PHI, and abide by the terms of this Notice. We reserve the right to change our Notice and to make the new provisions effective for all PHI we maintain. The revised Notices will be available in the Privacy Officer's office, in the Social Service Coordinator's office and in the main entrance area.
III. How We Will Use or Disclose Your PHI Without Your Written Authorization
1. Treatment: We may use and disclose your PHI for treatment. For example, a doctor treating you for a skin ulcer may need to review your health information if you have diabetes because diabetes may slow the healing process.
2 .Payment: We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide a copy of your care plan to your insurance company in order to get paid for the health care services we provided to you.
3. Healthcare Operations: We may use and disclose your PHI in order to operate our Facility. For example, members of the quality improvement committee may use information in your health record to assess the care and outcomes in your case and others like it. Business Associates provide services to us involving the use or disclosure of your PHI. Examples include a record destruction company we use to shred our discarded PHI, clinical laboratory services, and a consultant pharmacist who performs monthly medication reviews.
4. Law, Legal Proceedings, or Law Enforcement: We may make disclosures when a law requires that we report information to government agencies and law enforcement personnel about crime on the premises; victims of crime, abuse, neglect, or domestic violence; gunshot wounds; or when ordered by a subpoena or court order.
5. Serious Threat to Health or Safety: In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI. We may also disclose PHI to disaster relief agencies.
6. Research: We may provide PHI in order to conduct medical research, if the research has been approved.
7. Organ Donation: We may notify organ procurement organizations to assist them in organ, eye, or tissue donation or transplants.
8. Appointment Reminders, Health-Related Benefits and Services: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
9. Specific Government Functions: We may disclose PHI of military personnel and veterans in certain situations. We may disclose PHI for national security purposes, such as protecting the President of the United States or conducting intelligence operations.
10. Workers Compensation: We may disclose PHI in order to comply with the workers' compensation laws.
11. Public Health Activities: We may report your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
12. Health Oversight Agencies: We may disclose your PHI to the government when they conduct an investigation of our facility.
13. Deaths: We may disclose PHI to coroners, medical examiners, and funeral directors to determine the cause of death or to complete the death certificate.
14. Other Uses and Disclosures: Other uses and disclosures will be made only with your written permission. You may revoke an authorization to use or disclose PHI, except to the extent that action has already been taken.
IV. Facility and Clergy Directory - You Have the Choice of Objecting
Unless you notify us that you object, we may use your name, location in the Facility, and religious affiliation for facility and clergy directory purposes when you are admitted. (The facility directory is posted in a public area.) This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
V. Your Rights
1. Requesting Restrictions: Unless you notify us that you object, we may use your name, location in the Facility, and religious affiliation for facility and clergy directory purposes when you are admitted. (The facility directory is posted in a public area.) This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
2. Requesting Restrictions: You have the right to request a restriction or limitation on the PHI that we use or disclose about you. For example, you could ask that we not use or disclose information about a surgery that you had. However, the Facility is not required to agree to a requested restriction.
3. Receiving Confidential Communication of PHI: You have the right to ask that we send PHI to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, faxing instead of regular mail). We will attempt to accommodate all reasonable requests.
4. Inspecting and Copying Your PHI: You may request to inspect and/or obtain copies of your PHI. Within 24 hours of receiving the request to access your PHI, we will respond to your request. If you request copies, we will respond to the request within two working days advance notice and we will charge you a reasonable fee. At times we may deny your request and will inform you in writing.
5. Correcting or Updating Your PHI: If you believe that any PHI in your health record is incorrect, you may request that we correct the existing PHI or add the missing PHI (amend). Such requests must provide a reason to support the correction. We will respond within 60 days of receiving your request.
6. List of Disclosures: You may request that we provide you with a written list of all disclosures made by us within the last six years (not including information released prior to April 14, 2003). The list will not apply to any of the following disclosures: a) treatment, payment or healthcare operations; b) made to you or your legal representative, or any other individual involved with your care; c) disclosures to correctional institutions or law enforcement officials; d) disclosures for national security or intelligence purposes; and e) facility's directory. 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 fee.
7. Copy of This Notice: You have the right to obtain a paper copy or e-mail of our Notice.
To exercise any of your rights, please obtain the required forms from the Privacy Officer.
VI. Complaints
If you believe that your privacy rights have been violated, you may file a complaint. There will be no retaliation against you for filing a complaint. The complaint form may be obtained from the Privacy Officer or the Nurses' Stations. Return the completed form to:
Privacy Officer
Legacy Lodge Assisted Living
PO Box 777
Killdeer, ND 58640
T: 701-764-7116
You may also file a complaint with the Department of Health and Human Services, see below:
Office for Civil Rights, Department of Health & Human Services:
1961 Stout Street - Room 1426
Denver, CO 80294
T: 303-844-2024
F: 303-844-2025
TDD: 303-844-3439
E-Mail: OCRComplaint@hhs.gov