- Notice of Privacy Practices will be provided
on or before day of admission to
WVM.
- A signed copy of the Privacy Practices
will be maintained in the Resident
Financial File.
- A copy of the Privacy Practices will be
posted on a bulletin board or boards
located thought the facility for public display.
- The Privacy Practices policy will be posted
on the WVM web-site.
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.
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 nursing facility is required to:
- Maintain the privacy of your health information
- Provide you with this notice of our legal duties and
privacy practices with respect to information we collect
and maintain about you
- Abide by the terms of this notice
Your Rights
As a resident of our nursing facility, you have several rights
with regard to your health information, including the following:
- The right to request that we not use or disclose your
health information in
certain ways.
- The right to request to receive communications in an
alternative manner or
location.
- The right to request an amendment to your health information.
- The right to an accounting of disclosures of your health
information.
We reserve the right to change our policy 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 our web site. A copy of the revised notice will be
available after the effective date of the changes upon request.
We will not disclose your health information without your
authorization, except as described in this notice.
If have questions and would like additional information,
you may contact our facility’s Privacy Officer at 330-264-8640.
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, diagnosis, treatment, and a
plan for future care or treatment. This information, often
referred to as your health or medical record, serves as a:
- basis for planning you care and treatment
- means of communication among the many health professionals
who contribute
to your care
- legal document describing the care you received
- means by which you or a third-party payer can verify
that services billed were
actually provide
- a tool in educating health professionals
- a source of data for medical research
- a source of information for public health officials who
oversee the delivery of
health care in the United States
- a source of data for planning and marketing
- a tool with which we can assess and continually work to
improve the care we
render and the outcome we achieve
Understanding what is in your record and how your health
information is used helps you to: ensure its accuracy, better
understand who, what, 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 treatments 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’re 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 (c) the disclosure
must only be for one of the following purposes; (i) quality
assessment and improvement activities; (ii) population-based
activities relating 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) 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’ve asked them to
do. To protect your health information, however, we require
the business associates to appropriately safeguard your information.
(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.
(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
organization or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue
donation and transplant.
(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 maybe of interest to you, and the
payment for such product or service.
(12) Fund raising. We may contact you as part of a fund-raising
effort.
(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:
- You may request that we not use or disclose health information
for a particular reason related to treatment, payment, the
Facility’s general health care operations, and/ or
to a particular family member, other relative or close personal
friend. We ask that such requests be made in writing on
a form provided by our facility. “Although we will
consider your requests with regard to the use of your health
information, please be aware that we are under no obligation
to accept it or to abide by it. We will abide by your requests
with regard to the disclosure of your clinical and personal
records to anyone outside of the facility, except in an
emergency, if you are being transferred to another health
care institution, or the disclosure is required by law”.
42C.F.R. § 483.10(e) provides that a NF must abide
by a resident’s right to refuse the release of his/her
personal or clinical records to any individual outside of
the facility, unless the release is necessary because the
resident is being transferred to another health care institution,
or the it is required by law. for more information about
this right, see 45 Code of Federal Regulations (C.F.R.)§
164.522(a).
- If you are dissatisfied with the manner in which or the
location where you are receiving communications from us
that are related to you 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 West View Manor Privacy
Officer. We will attempt to accommodate all reasonable requests.
For more information about this right, see 45 C.F.R. §
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 45 C.F.R. §
164.542.
- If you believe that any health information in your records
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 C.F.R § 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 of health care operations;
disclosures made to you or your legal representative, or
any other individual involved with your care; 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.
§ 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.
For More Information or to Report
a Problem
If have questions and would like additional information,
you may contact our facility’s Privacy Officer at 330-264-8640.
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 form West View Manor Privacy Officer,
and when completed should be returned to West View Manor Privacy
Officer. 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:____________________
______________________________
Signature of Resident Date
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