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The
Plaza at Edgemere
NOTICE OF PRIVACY INFORMATION PRACTICES
As required by the Health Insurance Portability and Accountability Act
of 1996
Effective April 14, 2003
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
Please contact our Privacy Officer at 214-615-7045
if you have any questions regarding this notice.
A. General description and purpose of notice
This notice describes our information privacy practices and that of:
1. Any health care professional authorized to enter information into
your medical record created and/or maintained at our facility;
2. Any member of a volunteer group which we allow to help you while receiving
services at our clinic; and
3. All facility employees, staff, and other personnel.
All of the individuals or entities above will follow the terms of this
notice. These individuals or entities may share your health information
with each other for purposes of treatment, payment, or health care operations,
as further described in this notice.
B. Our facility’s policy regarding your health information
We are committed to preserving the privacy and confidentiality of your
health information created and/or maintained at our facility. Certain
state and federal laws and regulations require us to implement policies
and procedures to safeguard the privacy of your health information.
This notice will provide you with information regarding our privacy practices
and applies to all of your health information created and/or maintained
at our facility, including any information that we receive from other
health care providers or facilities. The notice describes the ways in
which we may use or disclose your health information and also describes
your rights and our obligations regarding any such uses or disclosures.
We will abide by the terms of this notice, including any future revisions
that we may make to the notice as required or authorized by law.
We reserve the right to change this notice and to make the revised or
changed notice effective for health information we already have about
you as well as any information we receive in the future. We will post
a copy of the current notice in our facility. The first page of the notice
contains the effective date and any dates of revision.
C. Uses or disclosures of your health information
We may use or disclose your health information in one of the following
ways:
(1) Pursuant to your written consent (for purposes of treatment, payment
or health
care operations)
(2) Pursuant to your written authorization (for purposes other than treatment,
payment or health care operations)
(3) Pursuant to your verbal agreement (for use in our facility directory
or to discuss
your health condition with family or friends who are involved in your
care)
(4) As permitted by law
(5) As required by law
The following describes each of the different ways that we may use or
disclose your health information. Where appropriate, we have included
examples of the different types of uses or disclosures. While not every
use or disclosure is listed, we may have included all of the ways in which
we may make such uses or disclosures.
1. Uses or disclosures made pursuant to your written request.
We may use or disclose your health information for purposes or treatment,
payment, or health care operations upon obtaining your written consent.
We may condition our delivery of services to you upon receiving your consent.
a. Treatment. We may use your health information to
provide you with health care treatment and services. We may disclose your
health information to doctors, nurses, nursing assistants, medication
aides, technicians, medical and nursing students, rehabilitation therapy
specialists, or other personnel who are involved in your health care.
For example, your physician may order physical therapy services to improve
your strength and walking abilities. Our nursing staff will need to talk
with the physical therapist so that we can coordinate services and develop
a plan of care. We also may disclose your health information to people
outside our facility who may be involved in your health care, such as
family members, social services, or home health agencies.
i. Appointment reminders. We may use or disclose your health information
for purposes of contacting you to remind you of a health care appointment
ii. Treatment alternatives, Health-related benefits and services. We may
use or disclose your health information for purposes of contacting you
to inform you of treatment alternatives or health-related benefits and
services that may be of interest to you.
b. Payment. We may use or disclose your health information
so that we may bill and collect payment from you, an insurance company,
or another third party for the health care services you receive at our
facility. For example, we may need to give information to your health
plan regarding the services you received form our facility so that your
health plan will pay us or reimburse you for the services. We also may
tell your health plan about a treatment you are going to receive in order
to obtain prior approval for the services or to determine whether your
plan will cover the treatment.
c. Health care operations. We may use or disclose your
health information to perform certain functions within our facility. These
uses or disclosures are necessary to operate our clinic and to make sure
that our residents receive quality care. For example, we may use your
health information to review our treatment and services and to evaluate
the performance of our staff in caring for you. We may combine health
information about many of our residents to determine whether certain services
are effective or whether additional services should be provided. We may
disclose your health information to physicians, nurses, nursing assistants,
medication aides, rehabilitation therapy specialists, technicians, medical
and nursing students, and other personnel for review and learning purposes.
We also may combine health information with information from other health
care providers or facilities to compare how we are doing and see where
we can make improvements in the care and services offered to our residents.
We may remove information that identifies you from this set of health
information so that others may use the information to study health care
and health care delivery without learning the specific identified of our
residents.
i. Fundraising activities. We may use a limited amount of your health
information for purposes of contacting you to raise money for our facility
and its operations. We may disclose this health information to a foundation
related to the facility so that the foundation may contact you to raise
money for our facility. The information which we may use or disclose will
be limited to your name, address, phone number, and dates for which you
received treatment or services at our facility. If you do not want our
facility or affiliated foundation to contact you for these fundraising
purposes, you must notify the Privacy Officer in writing.
2. Uses or disclosures made pursuant to your written authorization.
We may use or disclose your health information pursuant to your written
authorization for purposes other than treatment, payment, or health care
operations and for purposes which are not permitted or required law. You
have the right to revoke a written authorization at any time as long as
your revocation is provided to us in writing. If you revoke your written
authorization, we will no longer use or disclose your health information
for the purposes identified with the authorization. You understand that
we are unable to retrieve any disclosure which we may have made pursuant
to your authorization prior to its revocation. Examples of uses or disclosures
that may require your written authorization include the following:
a. A request to provide certain health information to
a pharmaceutical company for purposes of marketing
b. A request to provide your health information to an
attorney for use in a civil litigation claim
c. A request to provide your health information for purposes
of including you an a mailing list
3. Uses or disclosures made pursuant to your
verbal agreement.
We may use or disclose your health information pursuant to your verbal
agreement for purposes of including you in our facility directory or for
purposes of releasing information to persons involved in your case as
described below.
a. Facility directory. We may use or disclose certain
limited health information about you in our facility directory while you
are a resident at our facility. This information may include your name,
your assigned unit and room number, your religious affiliation, and a
general description of your condition. Your religious affiliation may
be given to a member of the clergy. The directory information, except
for religious affiliation, may be given to people who ask for you by name.
b. Individuals involved in your care. We may disclose
your health information to individuals, such as family and friends, who
are involved in your care or who help pay for your care. We also may disclose
your health information to a person or organization assisting in disaster
relief efforts for the purpose of notifying your family or friends involved
in your care about your condition, status and location.
4. Uses or disclosures permitted by law.
Certain state and federal laws and regulations either require or permit
us to make certain uses or disclosures of your health information without
your permission. These uses or disclosures are generally made to meet
public health reporting obligations or to ensure the health and safety
of the public at large. The uses or disclosures which we may make pursuant
to these laws and regulations include the following:
a. Public health activities. We may use or disclose
your health information
to public health authorities that are authorized by law to receive and
collect health information for the purpose of preventing or controlling
disease, injury, or disability. We may use or disclose your health information
for the following purposes:
i. To report births and deaths
ii. To report suspected or actual abuse, neglect, or domestic violence
involving a child or an adult
iii. To report adverse reactions to medications or problems with health
care products
iv. To notify individuals of product recalls
v. To notify an individual who may have been exposed to a disease or may
be at risk for spreading or contracting a disease or condition.
b. Health oversight activities. We may use or disclose
your health
information to a health oversight agency that is authorized by law to
conduct health oversight activities. These oversight activities may include
audits, investigations, inspections, or licensure and certification surveys.
These activities are necessary for the government to monitor the persons
or organizations that provide health care to individuals and to ensure
compliance with applicable state and federal laws and regulations.
c. Judicial or administrative proceedings. We may use
or disclose your
health information to courts or administrative agencies charged with the
authority to hear and resolve lawsuits or disputes. We may disclose your
health information pursuant to a court order, a subpoena, a discovery
request, or other lawful process issued by a judge or other person involved
in the dispute, but only if the efforts have been made to (i) notify you
of the request for disclosure or (ii) obtain an order protecting your
health information.
d. Worker’s compensation. We may use or disclose
your health
information to worker’s compensation programs when your health
condition arises out of a work-related illness or injury.
e. Law enforcement official. We may use or disclose
your health
information in response to a request form a law enforcement official for
the following purposes:
i. In response to a court order, subpoena, warrant, summons, or similar
lawful process
ii. To identify or locate a suspect, fugitive, material witness, or missing
person
iii. Regarding a victim of a crime if, under certain limited circumstances,
we are unable to obtain the person’s agreement
iv. To report a death that we believe may be the result of criminal conduct
v. To report criminal conduct at our facility
vi. In emergency situation, to report a crime---the location of the crime
and possible victims; or the identity, description, or location of the
individual who committed the crime.
f. Coroners, medical examiners, or funeral directors.
We may use or disclose your health information to a coroner or medical
examiner for the purpose of identifying a deceased individual to determine
the cause of death. We also may use or disclose your health information
to a funeral director for the purpose of carrying out his/her necessary
activities.
g. Organ procurement organizations or tissue banks.
If you are an organ donor, we may use or disclose your health information
to organizations that handle organ procurement, transplantation, or tissue
banking for the purpose of facilitating organ or tissue donation or transplantation.
h. Research. We may use or disclose your health information
for research purposes under certain limited circumstances. Because all
research projects are subject to a special approval process, we will not
use or disclose your health information for research purposes until the
particular research project for which your health information may be used
or disclosed has been approved through this special approval process.
However, we may use or disclose your health information to individuals
preparing to conduct the research project in order to assist them in identifying
residents with specific health care needs who may qualify to participate
in the research project. Any use or disclosure of your health information
which may be done for the purpose of identifying qualified participants
will be conducted onsite at our facility. In most instances, we will ask
for your specific permission to use or disclose your health information
if the researcher will have access to your name, address, or other identifying
information.
i. To avert a serious threat to health or safety. We may use or disclose
your health information when necessary to prevent a serious threat to
the health or safety of you or other individuals. Any such use or disclosure
would be made solely to the individual(s) or organization(s) that have
the ability and/or authority to assist in preventing the threat.
j. Military and veterans. If you are a member of the
armed forces, we may use or disclose your health information as required
by military command authorities.
k. National security and intelligence activities. We
may use or disclose your health information to authorized federal officials
for purposes of intelligence, counterintelligence, and other national
security activities, as authorized by law.
l. Inmates. If you are an inmate of a correctional institution
or under the custody of a law enforcement official, we may use or disclose
your health information to the correctional institution or to the law
enforcement official as may be necessary (i) for the institution to provide
you with health care; (ii) to protect the health and safety of you or
another person; (iii) for the safety and security of the correctional
institution.
5. Uses or disclosure required by law
We may use or disclose your information where such uses or disclosures
are required by federal, state, or local law.
D. Your rights regarding your health informationYou have the
following rights regarding your health information which we create and/or
maintain:
1. Right to inspect and copy. You have the right
to inspect and copy health information that may be used to make decisions
about your care. Generally, this includes medical and billing records,
but does not include psychotherapy notes.
To inspect and copy your health information, you must submit your request
in writing to Medical Records. If you request a copy of the information,
we may charge a fee for the costs of copying, mailing, or other supplies
associated with your request.
We may deny your request to inspect and copy your health information
in certain limited circumstances. If you are denied access to your health
information, you may request that the denial be reviewed. Another licensed
health care professional selected by our facility will review your request
and the denial. The person conducting the review will not be the person
who initially denied your request. We will comply with the outcome of
this review.
2. Right to request an amendment. If you feel
that the health information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request
an amendment for as long as the information is kept by or for our facility.
To request an amendment, your request must be made in writing and submitted
to Medical Records. In addition, you must provide us with a reason that
supports your request.
We may deny your request for an amendment if it is not in writing or
does not include a reason to support the request. In addition, we may
deny your request if you ask us to amend information that
a. was not created by us, unless the person or entity that created the
information is no longer available to make the amendment
b. is not part of the health information kept by or for our facility
c. is not part of the information which you would be permitted to inspect
and copy
d. is accurate and complete
3. Right to an accounting of disclosures. You
have the right to request an accounting of disclosures which we have made
of your health information. This accounting will not include disclosures
of health information that we made for purposes of treatment, payment,
or health care operations.
To request an accounting of disclosures, you must submit your request
in writing to the Privacy Officer. Your request must state a time period
which may not be longer than six (6) years prior to the date of your request
and may not include dates before April 14, 2003. Your request should indicate
in what form you want to receive the accounting (for example, on paper
or via electronic means). The first accounting that you request within
a twelve (12)-month period will be free. For additional accountings, we
may charge you for the costs of providing the accounting. We will notify
you of the cost involved, and you may choose to withdraw or modify your
request at that time before any costs are incurred.
4. Right to request restrictions. You have the
right to request a restriction or limitation on the health information
we use or disclose about you for treatment, payment, or health care operations.
You also have the right to request a limit on the health information we
disclose about you to someone, such as a family member or friend, who
is involved in your care. For example, you could ask that we not use or
disclose information regarding a particular treatment that you received.
We are not required to agree to your request. If we do
agree, we will comply with your request unless the information is needed
to provide emergency treatment to you.
To request restrictions, you must make your request in writing to Medical
Records. In your request, you must tell us (a) what information you want
to limit; (b) whether you want to limit our use, disclosure or both; and
(c) to whom you want the limits to apply (for example, disclosures to
a family member).
5. Right to request confidential communications.
You have the right to request that we communicate with you about your
health care in a certain way or at a certain location. For example, you
can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in
writing to Director of Nursing. We will not ask you the reason for your
request. We will accommodate all reasonable requests. Your request must
specify how or where you wish to be contacted.
6. Right to a paper copy of this notice. You have the right to receive
a paper copy of this notice. You may ask us to give you a copy of this
notice at any time. Even if you have agreed to receive this notice electronically,
you are still entitled to a paper copy of this notice.
You may obtain a copy of this notice on our Web site www.edgemeredallas.com
To obtain a paper copy of this notice, contact the Privacy Officer.
E. Complaints
If you believe your privacy rights have been violated, you may file a
complaint with our facility or with the secretary of the Department of
Health and Human Services. To file a complaint with our facility, contact
the Privacy Officer at 214-615-7045. All complaints must be submitted
in writing.
You will NOT be penalized for filing a complaint.
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