Notice of Privacy Practices
This notice describes how information about you may
be used and disclosed and how you can get access to this
information.
Please review carefully.
Evergreen Retirement Community must
maintain the privacy of your protected health
information and give you this notice describing our
legal duties and privacy practices concerning your
protected health information. In general, when we
release your health information, we must release only
the information we need to achieve the purpose of the
use or disclosure. However, all of your protected
health information will be available for release to you
or to a provider for treatment purposes.
Evergreen Retirement Community must follow the
privacy practices described in this notice. We reserve
the right to change the privacy practices described in
this notice, in accordance with the law. Changes to our
privacy practices would apply to all protected health
information we maintain. Should our privacy practices change,
a notice will be placed in the Evergreen Resident Journal newsletter.
A copy of the revised regulations will be posted on Evergreen bulletin
boards. You may request a copy of the revised regulations be mailed to you at the
address you have provided to Evergreen.
The following is a summary of the
circumstances under which and purposes for which your health information
may be used or disclosed.
Ø
We will use your protected health
information for treatment.
For example, nurses,
physicians, or other members of your health care team will use your
health information to provide care to you and develop an appropriate
plan of care. We may also disclose your health information to
individuals outside of the facility who are involved in your care,
including family members, pharmacists, suppliers of medical equipment
and other health care professionals.
We will
also provide appropriate information to subsequent health care providers
to assist them in treating you once you are discharged from Evergreen.
Ø We
will use your protected health information for payment.
A bill may be sent to you
or a third-party payer. The information on or accompanying the bill may
include information that identifies you, as well as your diagnosis,
procedures and supplies used.
Ø We
will use your protected health information for health care operations.
We may use and disclose
your health information for our own operations in order to facilitate
the functions of the facility and as necessary to provide quality care
to all residents. Our health care operations include activities such
as:
- Quality
assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol
development, case management and care coordination.
- Contacting health care providers and residents with
Information
about treatment alternatives and other related functions that do not
include treatment.
- Professional review and performance evaluations.
- Training
programs including those in which students, trainees or
practitioners in health care learn under supervision.
- Training
of non-health care professionals.
- accreditation, certification, licensing or credentialing activities.
- Review
and auditing, including compliance review, medical reviews, legal
services and compliance programs.
- Business
planning and development including cost management and planning
related analyses and formulary development.
- Business
management and general administrative activities of the facility.
- Fundraising for the benefit of the facility and certain marketing
activities.
For example, health care providers or members of the quality assurance team
may use information in your health record to assess the care and results
of services provided. This information will then be used to continually
improve the quality and effectiveness of the health care and service we
provide. We may also disclose your health information to staff and
contracted personnel for training purposes.
Ø
We may disclose your protected health
information for health oversight activities.
We
may disclose your health information to authorities so they can monitor,
investigate, inspect, discipline or license those who work in the health
care system or for government benefit programs.
Ø We
may use and disclose your protected health information for emergency
notification purposes. We
may use or disclose protected health information to notify or assist in
notifying a legal representative or another person responsible for your
care regarding a significant change in condition or an emergency
situation.
Ø We
may disclose your protected health information for disaster relief.
We may release your health
information to organizations authorized to handle disaster relief
efforts, such as the Red Cross, so those who care for you can receive
information about your location or health status. You may agree or
disagree orally to such release, unless there is an emergency.
Ø We
may use and disclose your protected health information for research
purposes.
We may request the use of
your health information for research. Before we disclose any of your
protected health information for research purposes, the project will be
subject to review by the Evergreen Retirement Community Research
Committee. When appropriate, we will request your written authorization
before granting access to your individually identifiable health
information.
Ø We
may use and disclose your protected health information to avoid a
serious threat to health or safety -
As required by law and
standards of ethical conduct, we may release your health information to
the proper authorities if we believe, in good faith, that such release
is necessary to prevent or minimize a serious threat to you or public
health and safety.
Ø We
may use and disclose your protected health information for activities
related to death.
We may disclose your health information to
coroners, medical examiners and funeral directors so they can carry out
their duties related to your death, such as identifying the body,
determining cause of death, or in the case of funeral directors, to
carry out funeral preparation activities.
Ø
We may use and disclose your protected health information for workers’
compensation. We may
disclose your health information to the appropriate persons in order to
comply with the laws related to workers’ compensation or other similar
programs. These programs may provide benefits for work-related injuries
or illness.
Ø We
may use and disclose your protected health information for organ, eye or
tissue donation.
We may disclose your health information to
people involved with obtaining organs, eyes or tissue for donation
purposes.
Ø We
may use and disclose your protected health information for public health
activities. We may be
required to report your health information to authorities to help
prevent or control disease, injury or disability, report disease,
injury, vital events such as birth or death and the conduct of public
health surveillance, investigations and interventions. We may also use
your health information to make reports to the Food and Drug
Administration (FDA) regarding adverse events and post–marketing
surveillance related to products regulated by the FDA. We may also need
to disclose your health information for purposes of notifying a person
who has been exposed to a communicable disease or who may be at risk of
contracting or spreading a disease or your employer of certain
work-related illnesses and injuries so that your workplace can be
monitored for safety.
Ø
We may use and disclose your protected health information as required or
permitted by law.
Sometimes we must report some of your health information to legal
authorities, such as law enforcement officials, court officials, or
government agencies. For example, we may have to report abuse, neglect,
domestic violence or certain physical injuries, or respond to a court
order.
Ø We
may use and disclose your protected health information for specified
government functions. In
certain circumstances, the federal regulations authorize us to use or
disclose your health information to facilitate specified government
functions relating to the military and veterans, national security and
intelligence activities, protective services for the President and
others, medical suitability determinations and inmates and law
enforcement custody.
Ø We
may use and disclose your protected health information for fundraising.
We may use your name and
other demographic information to send communications to you and/or your
family for purposes of supporting the Care Assurance Program or other
Evergreen projects. If you do not wish to receive fundraising
materials, notify the front office staff at (920-233-2340).
Ø We
may use and disclose your protected health information for purposes of
an internal resident directory.
We maintain a resident directory for
internal use that includes your name, address and phone number. This
directory is updated periodically. If you do not want to be included in
this directory, notify the front office staff at (920-233-2340).
Ø We
may disclose your religious affiliation to clergy unless you opt out.
Evergreen compiles a list
of residents by religious affiliation to provide to clergy. If you do
not want to be included on this list, notify the front office staff at
(920-233-2340).
Authorization to Use and Disclose Health
Information. Other than is
stated above, we will not disclose your health information other than
with your written authorization. If you or your representative
authorizes us to use or disclose your health information, you may revoke
that authorization in writing at any time.
Your
Health Information Rights
You have several rights with regard to
your health information. If you wish to exercise any of the following
rights, please contact the Medical Records Coordinator/Privacy Officer
at 920-237-2151.
Specifically, you have the right to:
Ø Access, visually inspect and copy your
health information. Your
record is stored in a secure area until destroyed (seven years after
discharge or death). You will be charged the Evergreen customary fee
for photocopying of your record.
Ø Request a correction or amendment to your health information.
If you believe your health information
is incorrect, you may ask us to correct the information. You will be
asked to make such requests in writing and give a reason as to why your
health information should be changed. If we did not create the health
information that you believe is incorrect, or if we disagree with you
and believe your health information is correct, we can deny your
request. Amendments to records are made in the form of addenda to the
record since changes and/or deletions are not allowed.
Ø Request restrictions on certain uses and
disclosures. You have the
right to ask for restrictions on how your health information is used or
to whom your information is disclosed. Or, you may want to limit the
health information provided to family or friends involved in your care
or payment of medical bills. You may also want to limit the health
information provided to authorities involved with disaster relief
efforts. We are not required to agree in all circumstances to your
requested restriction.
Ø Receive confidential communication of
health information, as applicable.
You have the right to ask that we
communicate your health information to you in different ways or places.
For example, you may wish to receive information about your health
status in a special, private room or through a written letter sent to a
private address. We will accommodate reasonable requests.
Ø Receive a record of disclosures of your
health information. You have
the right to ask for a list of the disclosures of your health
information. This list must include the date of each disclosure, who
received the disclosed health information, a brief description of the
health information disclosed, and why the disclosure was made. We will
comply with your request for a list within 60 days, unless you agree to
a 30-day extension, and we may not charge you for the list, unless you
request such a list more than once per year. We will not include
certain disclosures in this listing, including those made resulting from
your written authorization.
Ø Obtain a paper copy of this notice.
Upon your request, you may at any time receive a paper copy of this
notice.
Ø Complain.
If you believe your privacy rights have been violated, you may file a
complaint with the Medical Records Coordinator who is the designated
Privacy Officer for Evergreen Retirement Community (920-237-2151) or
with the Corporate Compliance Officer at Evergreen (920-237-2130) or
with the Office for Civil Rights, U.S. Department of Health and Human
Services. You will not be
retaliated against in any way for filing a complaint.
Effective Date:
April 14, 2003
PRIVACY REGULATIONS/MW/10/15/2002
REV. 11/13/02/4/1/03/final
REV. 12/22/2003
REV. 6/30/2005
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