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EPISCOPAL CHURCH HOME & AFFILIATES LIFECARE COMMUNITY, INC.
705 Renaissance Drive
Williamsville, New York 14221
PRIVACY NOTICE 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.
The first page of this notice provides a summary of the content within. Please refer to the full Privacy Notice for a complete description of our privacy practices, concerning your information, your rights and our responsibilities. You may review the Privacy Notice now or at a later time. At some point, you should read it carefully, because it explains: (1) generally, how we use health care information about you; (2) that we, like other health care providers, may use and disclose health information about you as part of your treatment, to arrange for payment for health care services, and for our internal
operations; (3) other circumstances where we may use or disclose health-related information about you (with or without your permission); and (4) the rights you have with respect to your health information, namely:
a. Your right to receive a copy of this Privacy Notice;
b. Your right to get a copy of your paper or electronic medical record;
c. Your right to receive an accounting of certain disclosures that we make of your health information;
d. Your right to request restrictions on how we use and disclose your health information;
e. Your right to request that we communicate with you at alternative locations, mailing addresses or telephone numbers;
f. Your right to request amendments to your health information;
g. Your right to revoke an authorization that we obtained to disclose your health information;
h. Your right to complain about suspected violations of your privacy rights;
i. Your right to choose someone to act for you; and
j. Your right to receive prompt notification if a breach occurs that may have compromised the privacy or security of your health information.
At Canterbury Woods, we take confidentiality seriously. We encourage you to read this Privacy Notice and keep a copy of this Privacy Notice for your records. – 2 –
EPISCOPAL CHURCH HOME & AFFILIATES LIFECARE COMMUNITY, INC. “CANTERBURY WOODS” 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.
A. OUR POLICY REGARDING YOUR HEALTH INFORMATION
We are committed to preserving the privacy and confidentiality of your health information. This Privacy Notice describes how Canterbury Woods may use and disclose your protected health information according to applicable laws and regulations. It also describes your rights with respect to your protected health information. Your protected health information includes most information about your physical and mental health, such as symptoms, treatment, test results, and demographic data, which contain details that can be used to identify you. We will not use or share your protected health information other than as described in this notice unless you authorize us to do so in writing. We will never share your protected health information for marketing or sell your protected health information. We are required by law to maintain the privacy of your protected health information and to provide you with this Privacy Notice of your rights, our legal duties and our privacy practices with respect to your protected health information. We are required to follow the duties and privacy practices described in this notice.
B. OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION
We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need these records to provide for your care and to comply with certain legal requirements.
C. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
You will be or have already been asked to sign a “Consent” allowing us to use and disclose your Protected Health Information to others to provide you with treatment, obtain payment for our services, and run our health care operations. This is a broad consent that we obtain on a one time basis. A consent is different than an “Authorization” and is required because of New York State law. An Authorization contains an expiration date or expiration event and provides detailed information about who may receive your protected health information and for what purposes your protected health information may be disclosed. The Health Insurance Portability and Accountability Act (“HIPAA”) provides the definition of “Authorization” and spells out what an authorization should contain and when an authorization is and is not required. Here are – 3 – examples of how we may use and disclose your health information with your consent, but without your authorization: For Treatment. Canterbury Woods may review and record information in your record about your treatment and care. We will use and disclose this health information to health care professionals in order to treat and care for you. For example, a Canterbury Woods physician may consult with a physician located at an outside facility to determine how to best diagnose and treat you. We may use your protected health information to remind you that you have an appointment and to recommend health related benefits or services that may be helpful. For Payment. Canterbury Woods may use and disclose your Protected Health Information to others in order for us to bill for your health care services and receive payment. For example, we may include your health information in our claim to Blue Cross/Blue Shield or Medicare in order to receive payment for services provided to you. We may also disclose your health information to other health care providers so that they can receive payment for your services. For Health Care Operations. We may use and disclose your Protected Health Information to others for our business operations. For example, we may use Protected Health Information to evaluate our services, including the performance of our staff, and to educate our staff.
D. USES AND DISCLOSURES WHERE YOU HAVE THE RIGHT TO OBJECT
Facility Directory. Unless you object, we may include general information about you in our facility/program directory. This information may include your name, location, general condition and religious affiliation. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. Your religious affiliation may be given to any member of the clergy even if they don’t ask for you by name. Family and Friends Involved in Your Care. Unless you object, we may disclose your Protected Health Information to a family member or close personal friend, including clergy, who is involved in your care or payment for that care.
E. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR OTHER SPECIFIC PURPOSES WITHOUT YOUR CONSENT OR AUTHORIZATION
Disaster Relief. We may disclose your Protected Health Information to an organization assisting in a disaster relief effort. Public Health Activities. We may disclose your Protected Health Information for public health activities including the reporting of disease, injury, vital events, and the conduct of public health surveillance, investigation and/or intervention. We may also disclose your information to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition if a law permits us to do so. Health Oversight Activities. We may disclose your Protected Health Information to health oversight agencies authorized by law to conduct audits, investigations, inspections and licensure – 4 – actions or other legal proceedings. These agencies provide oversight for the Medicare and Medicaid programs, among others. Personal Representatives. We may disclose your protected health information to or according to the direction of a person who, under applicable law, has the authority to represent you in making decisions related to your health. For example, we may disclose your protected health information to a legal guardian, health care agent or other person who by law is allowed to make health care decisions for you in the event you are unable to make your own health care decisions. De-identified Information: We may de-identify your protected health information according to specific federal rules so that the information does not identify you and cannot be used to identify you. We may use and disclose your de-identified information. We may also partly de-identify your protected health information by removing your name, address, telephone number and many other identifying factors to create a limited data set, which may be used and disclosed for research purposes. Your protected health information will only be disclosed in the form of a limited data set to recipients who sign an agreement to use your protected health information for specific purposes according to law and who agree not to identify you. Reporting Victims of Abuse, Neglect or Domestic Violence. If we have reason to believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your Protected Health Information to notify a government authority if required or authorized by law, or if you agree to the report. Law Enforcement. We may disclose your Protected Health Information for certain law enforcement purposes or other specialized government functions. Judicial and Administrative Proceedings. We may disclose your Protected Health Information in the course of certain judicial or administrative proceedings. Research. In general, we will request that you sign a written authorization before using your Protected Health Information or disclosing it to others for research purposes. However, we may use or disclose your health information without your written authorization for research purposes provided that the research has been reviewed and approved by a special Privacy Oversight Committee and de-identification maintained. Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiners, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue. To Avert a Serious Threat to Health or Safety. We may use and disclose your Protected Health Information when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat. Military and Veterans. If you are a member of the armed forces, we may use and disclose your Protected Health Information as required by military command authorities. We may also use and – 5 – disclose Protected Health Information about foreign military personnel as required by the appropriate foreign military authority. Workers’ Compensation. We may use or disclose your Protected Health Information to comply with laws relating to workers’ compensation or similar programs. National Security and Intelligence Activities: Protective Services. We may disclose health information to authorized federal officials who are conducting national security and intelligence activities or as needed to provide protection to the President of the United States, or other important officials. As Required By Law. We will disclose your Protected Health Information when required by law to do so. Treatment Alternatives and Health-Related Benefits. Canterbury Woods may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. Fundraising. Canterbury Woods may contact you or your designated representative to raise money to help us operate. We may also share your demographic information with a charitable foundation that may contact you or your designated representative to raise money on our behalf. You have the opportunity to opt out or restrict your receiving fundraising communications, by contacting our Health Information Management Coordinator (“HIM Coordinator”), whose contact information appears on page 7 of this Privacy Notice.
F. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF YOUR PROTECTED HEALTH INFORMATION
We will use and disclose your Protected Health Information other than as described in this Notice or required by law only with your written Authorization. You make revoke your Authorization to use or disclose Protected Health Information in writing, at any time. To revoke your Authorization, contact our HIM Coordinator. Contact information is provided on page 7. If you revoke your Authorization, we will no longer use or disclose your Protective Health Information for the purposes covered by the Authorization, except where we have already relied on the Authorization.
G. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights with respect to your protected health information. If you wish to exercise any of these rights, you should make your request to our HIM Coordinator, whose contact information appears on page 7. Right of Access to Protected Health Information. You have the right to request, to inspect and obtain a paper or electronic copy of your Protected Health Information, subject to some limited exceptions. We will respond to your request for an inspection within 10 days and generally respond to requests for copies within 30 days. If we need additional time we will – 6 – notify you within 30 days to explain the reason for the delay. We may charge a reasonable fee for our costs in copying and mailing your requested information. In certain limited circumstances, we may deny your request to inspect or receive copies. If we deny access to your Protected Health Information, we will provide you with a summary of the information, and you have a right to request review of the denial. We will provide you with information on how to request a review of our denial. Right to Request Restrictions. You have the right to request restrictions on the way we use and disclose your Protected Health Information for our treatment, payment or health care operations. You also have the right to restrict your Protected Health Information that we disclose to a family member, friend or other person who is involved in your care or the payment for your care. We are not required to agree to your requested restriction, and in some cases, the law may not permit us to accept your restriction. However, if we do agree to accept your restriction, we will comply with your restriction except if you are being transferred to another health care institution, the release of records is required by law, or the release of information is needed to provide you emergency treatment. To request restrictions, you must submit a written request to our HIM Coordinator, whose contact information is listed on page 7 of this Privacy Notice. In your written request, you must identify the specific restriction requested and identify whom you want the restrictions to apply to. If we deny your request to a restriction, we will notify you. Under certain circumstances, we may terminate our agreement to a restriction. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or health care operations with your health insurer. We will say “yes” unless a law requires us to share that information. Right to an Accounting of Disclosures. You have the right to request an “accounting” of our disclosures of your Protected Health Information in the past six (6) years. This is a listing of certain disclosures of your Protected Health Information made by Canterbury Woods or by others on our behalf, but does not include disclosures made for treatment, payment and health care operations or certain other exceptions. You must submit a request in writing, stating a time period that is within six years from the date of your request. You are entitled to one free accounting within one 12 month period. For additional requests, we may charge you our costs. We will usually respond to your request within 60 days. Occasionally, we may need additional time to prepare the accounting. If so, we will notify you of our delay, the reason for the delay, and the date when you can expect the accounting. Right to Breach Notification. You have the right to be promptly notified if a breach occurs that may have compromised the privacy or security of your health information. Right to Request Amendment. If you think that your Protected Health Information is not accurate or complete, you have the right to request that the we amend such information for as – 7 – long as the information is kept in our records. Your request must be in writing and state the reason for the requested amendment. We will usually respond within 60 days, but will notify you within 60 days if we need additional time to respond, the reason for the delay and when you can expect our response. We may extend the time by no more than an additional 30 days. We may deny your request for amendment, and if we do so, we will give you a written denial including the reasons for the denial and an explanation of your right to submit a written statement disagreeing with the denial. Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You may obtain a copy if this Notice at our website, www.echa.org or www.canterburywoods.org. Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example, you can request that we speak to you only at certain private locations in the facility. We will accommodate your reasonable requests. We may condition this accommodation on your providing us with information as to how payment will be handled or by specifying an alternative address or other method of contact. We will not require you to provide us with an explanation for the basis of your request.
If your believe that your privacy rights have been violated, you may file a complaint. You have the right to complain to us, and/or to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. You may complain to us by contacting the Corporate Compliance Officer, using the contact information below. We will not retaliate against you for filing a complaint. The contact person for all issues regarding patient privacy questions and your rights under the federal privacy standards is our Corporate Compliance Officer, whom you may contact:
Episcopal Church Home & Affiliates Lifecare Community, Inc.
705 Renaissance Drive
Williamsville, New York 14221
You may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Avenue, S.W., Washington, D.C., 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. – 8 –
I. CHANGES TO THIS NOTICE
We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all Protected Health Information already received and maintained by the Episcopal Church Home & Affiliates Lifecare Community, Inc. as well as for all Protected Health Information we receive in the future. We will post a copy of the current Notice in each facility and on our website. You may obtain a copy by asking our Corporate Compliance Officer for one, by printing it from our website or by taking a copy from the copies available at our facility.
J. FOR FURTHER INFORMATION
If you have any questions about this Notice or would like further information concerning your privacy rights, please contact the Corporate Compliance Officer at (716) 929-5800. Revised Date of this Notice: 12/31/13; 2015 Doc #01-2719667.1