THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

DuBois Nursing Home is required by law to provide you with this notice so that you will understand how we may use or share your medical information.  We are required to adhere to the terms outlined in this notice.  If you have any questions about this notice which are not answered upon admission, please contact the social worker assigned to you.

This notice describes the practices of DuBois Nursing Home and its affiliates.  DuBois Nursing Home is required by law to provide you with this notice regarding our legal obligations with respect to your protected health information and to adhere to the terms of the notice currently in effect.

UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION

During your stay at DuBois Nursing Home a complete record of your stay is made.  Typically, this record contains information about your condition and the treatment that we provide.  We safe guard your record to the best of our ability.  We only share the information within it with  the health care providers and contractors involved in your care and the governmental agencies charged with regulatory compliance.  In no case do we provide it to any person or organization using the information for any purpose other than making sure your care is appropriate for your needs.  We use and/or disclose this information to:

·         plan your care and treatment

·         communicate with other health professionals involved in your care

·         document the care you receive

·         educate health professionals

·         provide information for medical research

·         provide information to public health officials

·         evaluate and improve the care we provide

Understanding what is in your record and how your health information is used helps you to:

·         ensure it is accurate

·         better understand who may access your health information

·         make more informed decisions when authorizing disclosures to others

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe the ways that use and disclose medical information.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall into one of the categories.

·         For Treatment.  We may use medical information about you to provide you with medical treatment.  We may disclose medical information about you to doctors, nurses, therapists or other DuBois Nursing Home facility personnel who are involved in taking care of you.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian if you have diabetes so that we can plan your meals.  Different departments at DuBois Nursing Home also may share medical information about you in order to coordinate your care and provide you medication, lab work and x-rays.  We may also disclose medical information about you to people outside DuBois Nursing Home who may be involved in your medical care after you leave DuBois Nursing Home.  This may include family members, or visiting nurses to provide care in your home.   

·         For Payment.  We may use and disclose medical information about you so that the treatment and services you receive at DuBois Nursing Home may be billed to you, an insurance company or a third party.  For example, in order to be paid, we may need to share information with your health plan about services DuBois Nursing Home provided to you.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

·         For Health Care Operations.  We may use and disclose ,medical information about you for health care operations.  This is necessary to ensure that all of our residents receive quality care.  For example, we may use medical information to review our services and to evaluate the performance of our staff.  We may combine medical information about many DuBois Nursing Home residents to decide what  additional services we should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to doctors, nurses, therapists, and other DuBois Nursing Home personnel for review and learning purposes.  We may remove information that identifies you so others may use it to study health care and health care delivery without learning the identities if residents.

OTHER ALLOWABLES USES OF YOUR MEDICAL INFORMATION

·         Business Associates. There are some services provided in our organization through contracts with business associates.  Examples include medical directors, outside attorneys and a billing service we use on occasion.  When these services are contracted, we may disclose your health information so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered.  To protect your health information, however, we require the business associate to appropriately safeguard your information.

·         Providers.  Participants in one of our organized healthcare arrangements offer many services provided to you, as part of your care at our facility.  These participants include a variety of providers such as physicians (i.e. MD, DO, Podiatrist, Dentist, Optometrist), therapies (i.e. Physical Therapist, Occupational Therapist, Speech Therapist), portable radiology units, clinical labs, hospice caregivers, pharmacies, psychologists, LCSWs, and suppliers (i.e. prosthetic, orthotics).  Please note that the physicians who care for our residents are not employed or contracted by DuBois Nursing Home; they work independently and outside of our control.

·         Treatment Alternatives.  We may use and disclose medical information to tell you about possible treatment options or alternatives that may be of interest to you.

·         Health-related Benefits and Services.  We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you.

·         Fundraising Activities.  We may use medical information about you to contact you in an effort to raise money as part of a fundraising effort.  We may disclose medical information to a foundation or other endowment manager related to DuBois Nursing Home so that the foundation may contact you in raising money for the DuBois Nursing Home.  We will only release contact information, such as your name, address and phone number and the dates you received treatment or services at the DuBois Nursing Home.

·         If you do not want contacted for fundraising efforts, you must notify the DuBois Nursing Home Administrator in writing.

·         DuBois Nursing Home Facility Directory.  While we do not keep a directory of residents in public view, such information is available at the reception desk.  This information may include your name, location in the DuBois Nursing Home facility, your general condition (i.e. fair, stable, etc.) and your religion.  The directory information, except for your religion, may be disclosed to people who ask for you by name.  Your religion may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name.  This is so your family, friends and clergy can visit you at the DuBois Nursing Home and generally know how you are doing.

·         Individuals Involved in Your Care or Payment for Your Care.  We may disclose medical information about you to a friend or family member who is involved in your care.  We may also tell your family or friends your condition and that you are in DuBois Nursing Home. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

·         As Required By Law.  We will disclose medical information about you when required to do so by federal, state, or local law.

·         To Avert a Serious Threat to Health or Safety.  We may use and disclose medical information about you to prevent a serious threat to your health and safety or the health and safety of the public or another person.  We would do this only to help prevent the threat.

·         Research.  We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

·         Funeral Directors.  We may disclose health information to funeral directors and coroners to carry out their duties consistent with applicable law.

·         Organ Procurement Organizations.  Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

·         Food and Drug Administration (FDA).  We may disclose to 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.

·         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.

·         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.

·         Law enforcement.  We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

·         Reports.  Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provide 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 RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Although your health record is the property of DuBois Nursing Home, the information belongs to you.  You have the following rights regarding your medical information:

·         Right to Inspect and Copy.  With some exceptions, you have the right to review and copy your medical information.

·         You must submit you request in writing to the DuBois Nursing Home Administrator.  We may charge a fee for the costs of copying, mailing or other supplies associated with your request.

·         Right to Amend.  If you feel that medical information in your record is incorrect or incomplete, you may ask us to amend the information.  You have this right for as long as the information is kept by or for the DuBois Nursing Home facility.

·         You must submit your request in writing to the DuBois Nursing Home Administrator.  In addition, you must provide a reason for you 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:

·         Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

·         Is not part of the medical information kept by or for DuBois Nursing Home; or

·         Is accurate and complete.

·         Right to an Accounting or Disclosures.  You have the right to request an “account of disclosures”.  This is a list of certain disclosures we made of your medical information, other than those made for purposes such as treatment, payment, or health care operations.

                You must submit your request in writing to the DuBois Nursing Home Administrator.  Your request must state a time period, which may not be longer than six(6) years from the date the request, is submitted and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (for example, on paper or electronically).  The first list you request within a 12-month period will be free.  For additional lists, we may charge you for the costs of providing the list.  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.

·         Right to Request Restriction.  You have the right to restrict or limitation on the medical information we use or disclose about you.  For example, you may request that we limit the medical information we disclose to someone who is involved in your care or the payment for your care.  You could ask that we not use or disclose information about a surgery you had to a family member or friend.

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 you emergency treatment. 

You must submit your request in writing to the DuBois Nursing Home Administrator.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

·         Right to Request Alternate Communications.  You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location.  For example, you may ask that we only contact you via mail to a post office box.

You must submit your request in writing to the DuBois Nursing Home Administrator.  We will not ask you the reason for your request.  Your request must specify how or where you wish to be contacted.  We will accommodate all reasonable requests.

·         Right to a Paper Copy of This Notice.  You have a right to a paper copy of this notice even if you have agreed to receive the notice electronically. You may ask us to give you a copy of this notice at any time.

*  You may obtain a copy of this notice at our website, www.duboisnursinghome.webatonce.com.

To obtain a paper copy of this notice, contact The DuBois Nursing Home Admissions Office.

Special Situations

·         Organ and Tissue Donation.  If you are an organ donor, we may disclose medical information to organizations that handle organ procurement to facilitate donation and transplantation.

·         Military and Veterans.  If you are a member of the armed forces, we may disclose medical information about you as required by military authorities.  We may also disclose medical information about foreign military personnel to the appropriate foreign military authority.

·         Research.  Under certain circumstances, we may use and disclose medical information about you for research purposes.  For example, a research project may involve comparing the health and recovery of all residents who received one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with residents’ need for privacy of their medical information.  Before we use or disclose medical information for research, the project will have been approved through this research approval process.  We may, however, disclose medical information about you to people preparing to conduct a research project so long as the medical information they review does not leave the DuBois Nursing Home.

·         Workers’ Compensation.  We may disclose medical information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

·         Public Health Risks.  We may disclose medical information about you for public health purposes, including:

·         Prevention or control of disease, injury or disability

·         Reporting births and deaths;

·         Reporting reactions to medications or problems with products;

·         Notifying people of recalls of products;

·         Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;

·         Notifying the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.

·         Health Oversight Activities.  We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities may include audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

·         Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order.  We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

·         Law Enforcement.  We may disclose medical information when requested by a law enforcement official:

·         In response to a court order, subpoena, warrant, summons or similar process;

·         To identify or locate a suspect, fugitive, material witness, or missing person;

·         About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain the your agreement;

·         About a death we believe may be the result of criminal conduct;

·         About criminal conduct at DuBois Nursing Home; and

·         In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

·         Coroners, Medical Examiners and Funeral Directors.  We may disclose medical information to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death.  We may also disclose medical information to funeral directors as necessary to carry out their duties.

·         National Security and Intelligence Activities.  We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

CHANGE TO THIS NOTICE

We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical 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 DuBois Nursing Home or on the website.  The notice will specify the effective date on the first page.  In addition, if material changes are made to this notice, the notice will contain an effective date for the revisions and copies can be obtained by contacting the DuBois Nursing Home Administrator.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with DuBois Nursing Home or with the Secretary of the Department of Health and Human Services.  To file a complaint with DuBois Nursing Home, contact the Administrator at 375-9100, or,  at the Reception Desk.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission.  If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.