CHESTELM
NURSING & REHABILITATION CENTER
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CHESTELM NURSING & REHABILITATION CENTER
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NOTICE OF PRIVACY PRACTICES(Click
here to download and/or print)
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. This Notice is effective
as of April 14, 2003. I.
APPLICABILITY This is a joint notice by Chestelm
Health and Rehabilitation Center (“Chestelm”) and its ON-SITE OR
VISITING MEDICAL ASSOCIATES, referred to jointly below as “the
Facility”, “we”, or “our”. “On-site
or visiting medical associates” includes [Facility’s] attending physicians,
physiatrists, wound care consultants, and other consultant physicians. As part of their joint arrangement,
Chestelm and its on-site or visiting medical associates may use or share health
information about you as necessary to carry out treatment, payment, or health
care operations, with one another and as described in the remainder of this
notice. If you have any questions about
this notice, please contact Chestelm’s Privacy Officer or his or her designee.
These individuals can be reached through Chestelm’s Business Office,
either in-person or by phone or mail at: Chestelm Health and Rehabilitation
Center Attention:
Privacy Officer 534 Town Street P.O. Box 719 (860)873-1455
II.
OUR COMMITMENT AND RESPONSIBILITY TO PROTECT YOUR
PRIVACY We respect the privacy and
confidentiality of your health information.
This Notice of Privacy Practices (“Notice”) applies to uses and
disclosures we may make of all your health information, whether created or
received by us, as outlined by the Health Insurance Portability and
Accountability Act (HIPAA) of 1996. Connecticut
State Law may further restrict some of the uses or disclosures described in this
Notice. It is our responsibility
and commitment to apply the appropriate state or federal standard when
safeguarding your privacy. We are required by HIPAA to: 1.
Maintain the privacy of your health information and to provide you with
notice of our legal duties and privacy practices. 2.
Comply with the terms of our Notice currently in effect. We reserve the right to change our
privacy practices and to make the new provisions effective for all health
information we maintain, including both health information we already have and
health information we create or receive in the future.
Should we make material changes to our privacy practices, we shall:
(1) Notify you accordingly; and (2) Provide you with a revised Notice by
posting it in a clear and prominent location in the Facility and by other means
as appropriate or necessary. III.
YOUR HEALTH INFORMATION MAY BE USED OR DISCLOSED FOR
THE FOLLOWING PURPOSES WITHOUT YOUR PRIOR AUTHORIZATION We may use and disclose your health
information for the following purposes without obtaining your written or
oral authorization, unless otherwise specified below, as permitted by Facility
policy and/or law: 1.
Treatment.
We may use and disclose your health information to provide you with
treatment and services and to coordinate your continuing care.
Your health information may be used by doctors and nurses, as well as by
lab technicians, dieticians, physical therapists or other persons involved in
your care, both within and outside of our Facility. For example, we may disclose certain information to our
pharmacist to fill a prescription ordered by your doctor, or to our suppliers
for procuring supplies or other items necessary for your care. 2.
Payment.
We may use and disclose your health information so that we can bill and
receive payment for the treatment and services you receive.
For billing and payment purposes, we may disclose your health information
to an insurance or managed care company, Medicare, Medicaid or another
third-party payer. For example, we
may contact Medicare or your health plan to confirm your coverage or to request
approval for a proposed treatment or service. 3.
Health Care Operations.
We may use and disclose your
health information as necessary for our internal operations, such as for general
administrative activities and to monitor the quality of care you receive with
us. For example, we may use your
health information to evaluate and improve the quality of care you received, for
education and training purposes, and for planning for services. 4.
Facility Directory.
We may use and disclose certain limited information about you in our
Directory while you are a resident or patient of the Facility.
This information may include your name, your location in the Facility,
your general condition and your religious affiliation.
You will be provided the opportunity to agree or object to (and
prohibit) the use and disclosure of some or all of your information in the
Facility Directory. 5.
Persons Involved in Your Care
or Payment for Your Care.
We may disclose your health information, only as appropriate and
relevant, to persons involved in your care or the payment for your care.
This includes family members, other relatives, close personal friends or
other persons you identify. When
possible, you will be provided the opportunity to agree or object to (and
prohibit) such use and disclosure of your health information. 6.
Notification.
We may use or disclose your health information to notify your family,
your “personal representative”, or another person responsible for your care,
of your physical location or of changes in the status of your health. When possible, you will be provided the opportunity to
agree or object to (and prohibit) such use or disclosure, unless it is required
in a disaster relief or similar emergency. 7.
As Required By Law.
We may disclose your health information when required by law to do so.
Such requirements include reporting incidents of abuse and complying with
court orders and law enforcement activities. 8.
Public Health Activities.
We may disclose your health information for public health activities,
such as authorized interventions to avoid the spread of a communicable disease. 9.
Reporting Abuse, Neglect or
Domestic Violence.
If we believe that you have been a victim of abuse, neglect or domestic
violence, we may disclose your health information to notify a government
authority, if authorized by law or if you agree to the report. 10.
Health Oversight Activities.
We may disclose your health information to state or federal health
oversight agencies for activities authorized by law.
For example, these activities may include audits, investigations,
inspections and licensure actions. 11.
Judicial and Administrative
Proceedings.
We may disclose your health information in response to a court or
administrative order. We also may
disclose information in response to a subpoena, discovery request, or other
lawful process. 12.
Law Enforcement.
We may disclose your health information for certain law enforcement
purposes, such as: Submitting
reports or providing information required by law; Reporting suspicion or
evidence of criminal conduct (occurring on the premises or in response to an
emergency); At the request of a law enforcement official for locating or
identifying an individual. Under
certain circumstances, you may object to (and prohibit) the use or disclosure of
your health information for law enforcement purposes. 13.
Decedent-Related Purposes. We may release your health information for decedent-related
purposes, including to a coroner, medical examiner, funeral director and, if you
are an organ donor, to an organization involved in the donation of organs and
tissue. 14.
Research and Contributing to
Generalizable Knowledge. Your health information may
be used or disclosed for research purposes or to contribute to generalizable
knowledge, but only if: (1) The privacy aspects of the research have been
reviewed and approved by a special Privacy Board or Institutional Review Board
and the Board can and does legally waive requirements for your authorization;
(2) The researcher represents that he or she is only reviewing the information
in preparation for a research proposal; (3) The research is occurring after your
death; or (4) You give written authorization for the use or disclosure. 15.
Averting a Serious Threat to
Health or Safety.
When necessary to prevent a serious threat to your health or safety, or
the health or safety of the public or another person, we may use or disclose
your health information to individuals able to minimize or prevent the
threatened harm (e.g., law enforcement officials). 16.
Specialized Government
Functions.
We may use or disclose your health information for specialized government
functions, as deemed necessary by appropriate command authorities or federal
officials. Such functions include:
(1) Military and Veterans Affairs; (2) National Security and Intelligence
Activities; (3) Protective Services for the President and Others; (4)
Correctional Institution or Other Law Enforcement Custodial Situations. 17.
Workers' Compensation.
We may use or disclose your health information to comply with laws
relating to workers' compensation or similar programs. 18.
Business Associates.
We may disclose your health information to our business associates under
a valid “Business Associate Agreement”, which stipulates the appropriate
exchange and subsequent use of your health information. 19.
Marketing Activities.
We may use your health information in an effort to market the facility
and/or its services to you – either in a face-to-face meeting with you or by
providing you with a promotional gift. 20.
Fundraising Activities.
We may use a subset of your health information to contact you in an
effort to raise funds for the Facility, including:
(1) Demographic information, such as your name, address, and phone
number; and (2) The dates of the health care services you received.
This information may also be disclosed to business associates assisting
in the fundraising initiative. 21.
Personal Representatives.
If you have an authorized “Personal Representative”, such as a
conservator of person or a health care power of attorney, this individual shall
be treated the same as you with respect to your health information.
This includes grants of full access to your health information, as well
as decision-making authority on its use and disclosure.
“Personal Representative” status may be denied, however, if we
determine such denial is in your best interest. 22.
Limited Data Sets.
We may use or disclose a subset of your health information in a
“limited data set”, for the purpose of research, public health, or health
care operations. Such use or
disclosure will exclude certain “direct identifiers”, such as your name or
medical record number, and will be carried out in accordance with statutory
regulations. 23.
Incident to a Permitted or
Required Use or Disclosure. We
may use or disclose your health information in a manner or for a purpose that is
“incidental” to a use or disclosure otherwise permitted or required by
applicable privacy statutes. For
example, we may post your name outside of your room or require that you wear an
identification bracelet that includes your name, the name of your doctor, and
your room number. We will limit all
such uses or disclosures to the minimum information necessary to achieve the
intended purpose. We will also
apply reasonable and appropriate safeguards to avoid unintended, unnecessary,
and non-permitted uses or disclosures of your protected health information. 24.
Treatment Alternatives and
Health-Related Benefits and Services.
We may use or disclose your health information to inform you about
treatment alternatives and health-related benefits and services that may be of
interest to you. IV.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR ALL USES OR
DISCLOSURES OF YOUR HEALTH INFORMATION NOT OTHERWISE DESCRIBED IN SECTION III
ABOVE 1.
We will obtain your written authorization (an “Authorization”) prior
to making any use or disclosure not otherwise described in Section III above. 2. You may revoke a written Authorization previously given by you at any time but you must do so in writing. If you revoke your Authorization, we will no longer use or disclose your health information for the purposes specified in that Authorization except where we have already taken actions in reliance on your original Authorization.
You have the following
rights regarding your health information: 1.
Right to Request Restrictions.
You have the right to request that we restrict the way we use or disclose
your health information for treatment, payment or health care operations, to
persons involved in your care or payment for your care, and for notification
purposes. However, we are not
required to agree to such restriction. We
will honor all restrictions that we agree to, except in the event of an
emergency, in which case we will only disclose the restricted information to the
extent necessary for your treatment. 2.
Right to Request Confidential
Communications.
You have the right to request that we communicate with you concerning
your health matters in an alternative manner or at an alternative location. For
example, you can request that we contact you only at a certain phone number. We
will accommodate your reasonable requests. 3.
Right of Access to Personal
Health Information.
You have the right to inspect and, upon written request, obtain a copy of
your health information. You may be
charged a cost-based fee for copies of your health information, not to exceed 65
cents per page, plus any applicable postage, plus a reasonable fee for x-ray
films. You may also request, and be
charged a cost-based fee for, a summary or explanation of this information.
If you cannot afford these fees, we may request that you provide us
evidence (e.g., an affidavit) attesting to that fact.
Your request for access may be denied under certain legal circumstances.
Depending on the reason for the denial, you may request review by a third
party. 4.
Right to Request Amendment. You have the right to request that we amend your health
information. Your request must be
made in writing and must state the reason for the requested amendment.
We will respond to your request in a timely manner, and as prescribed by
law. We may deny your request for
certain reasons permitted by law. If
we deny your request, you have the right to:
(1) File a statement with us disagreeing with the denial, or
alternatively, request that we provide your request and the subsequent denial
with any future disclosures of the health information in question; and (2) File
a complaint either with us or with the Department of Health and Human Services. 5.
Right to an Accounting of
Disclosures.
You have the right to request an “accounting” of certain disclosures
of your health information. This is
a listing of disclosures made by us or by others on our behalf, but does not
include disclosures for treatment, payment and health care operations or certain
other exceptions. For each disclosure/group of disclosures the accounting shall
include the date(s) of the disclosure(s); the name of the person or entity that
received the information and, if known, their address; a brief description of
the information disclosed; and a brief explanation of the reason(s) for the
disclosure(s). You
must submit your request for accounting in writing, including the time period
for which you would like the accounting. We
will respond to your request in a timely manner, and as prescribed by law.
The first accounting provided within a given 12-month period will be
free; we may charge a cost-based fee for additional accountings provided during
that period, not to exceed 65 cents per page, plus any applicable postage. 6.
Right to Obtain a Paper Copy of
this Notice.
You have the right to obtain a paper copy of the Facility’s Notice of
Privacy Practices upon request. A
copy of this notice is provided upon admission. VI.
COMPLAINTS If you believe that your privacy
rights have been violated, you may file a complaint with Chestelm’s Privacy
Officer or his or her designee. These
individuals can be reached through Chestelm’s Business Office, at the address
and phone number listed at the beginning of this Notice.
You may also file a complaint with the Secretary of Health and Human
Services at the following address: U.S.
Department of Health and Human Services – Office of Civil Rights, 200
Independence Avenue, S.W., Room 509 F, HHH Building, Washington D.C. 20201. We will not retaliate against you
in any way for filing a complaint against this Facility.
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534 Town Street, Moodus, CT 06469 (860) 873-1455
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