Notice of Privacy Practices

Compliance Policy

HIPAA 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 Facility understands that your medical information is private and confidential. Further, we are required by law to maintain the privacy of “PROTECTED HEALTH INFORMATION.” Protected health information includes any individually identifiable information that we obtain from you or others that relate to your past, present or future physical or mental health, the health care you have received, or payment for your health care.


As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to your protected health information. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all protected health information we maintain. A current copy of this notice will be maintained on our website. You can also request a written copy of our most current privacy notice from the Administrator of the Facility or by contacting our Privacy Officer at 1.844.758.1922 or


We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will not use or share your protected health information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Permitted Uses & Disclosures

We can use or disclose your protected health information for the purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.


Treatment: means provision, coordination management of your health care, including consultations between health care providers relating to your care and referrals for health care from one healthcare provider to another. For example, an Orthopedist treating you for a hip fracture may need to know if you are also being treated for any heart conditions. If so, the Orthopedist may need to speak to your Cardiologist, as well as a physical therapist, to ensure the appropriate course of treatment.


Payment: means the activities we undertake to obtain reimbursement for the health care provided to you, including billing collections, claims management, determinations of eligibility and coverage and other utilization review activities, for example, prior to providing healthcare services we may need to provide information to your Third Party Payor (such as Medicare, Medicaid or a private insurer) for the services rendered to you, we can provide the Third Party Payor with information regarding your care if necessary to obtain payment. Federal or State law may require us to obtain a written release from you prior to disclosing certain specially protected health information for payment purposes, and we will ask you to sign a release when necessary under applicable law.


Healthcare operations: means the support functions of the Facility related to treatment and payment, such as quality assurance activities, case management, receiving and responding to resident comments, and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. For example, we may use our protected health information to evaluate the performance of our staff when caring for you. We may also combine health information about many 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, nurse technicians, medical students and others for review and learning purposes. In addition, we may remove information so that others can use the de-identified information to study health care delivery without learning who you are.


Privacy Of MDS Data: MDS assessment data is personal information about nursing facility residents that facilities are required to collect and keep confidential in accordance with federal law. 42 CFR Part 483.20 requires Medicare and Medicaid certified nursing facility providers to collect the resident assessment data that comprises the MDS. This data is considered part of the resident’s medical record and is protected from improper disclosure by Medicare and Medicaid certified facilities by regulation. Nursing facility providers are also required under CFR 483.20 to transmit MDS data to a Federal data repository. Any personal data maintained and retrieved by the Federal government is subject to the requirements of the Privacy Act of 1974, as set forth in the Privacy Act Statement- Health Care Records provided to our residents upon admission.

Other Uses and Disclosures of Protected Health Information

In addition, to using and disclosing your information for treatment, payment and healthcare operations, we may use your protected health information in the following ways:

  • We may contact you to provide appointment reminders for treatment or medical care.
  • We may contact you to tell you about or recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.
  • We may disclose to your family or friends or any other individual identified by you, protected health information directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your protected health information to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. If you are present or otherwise available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not present or otherwise available, we will determine whether a disclosure to your family or friends is in your best interest taking in to account the circumstances and based upon our professional judgment.
  • When permitted by law, we may coordinate our uses and disclosures of protected health information with public or private entities authorized by law or by charter to assist in disaster relief efforts.
  • We will allow your family and friends to act on your behalf to pick-up filled prescriptions, medical supplies, x-rays, and similar forms of protected health information, when we determine, in our professional judgment that it is in your best interest to make such disclosures. We will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object.
  • We may contact you as part of our fundraising and marketing efforts as permitted by applicable law but only with your written permission.
  • We may use or disclose your protected health information for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of health and recovery of all residents who received a particular medication. All research projects are subject to a special approval process which balances research needs with a resident’s need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.
  • We can share protected health information with a coroner, medical examiner, or funeral director when an individual dies.
  • We can disclose your protected health information if state or federal laws require it, including information to the Centers for Medicare and Medicaid Services and the Department of Health and Human Services.
  • We can disclose your protected health information if we suspect that you are the victim of abuse, neglect or domestic violence.
  • We can disclose your protected heath information to workers’ compensation insurers, State administrators, employers, and other persons or entities involved in workers’ compensation systems to the extent necessary to comply with laws relating to workers’ compensation or similar programs established by law that provide benefits for work-related injuries or illness.

Your Rights Related to Your Protected Health Information

  • You can ask to see or get an electronic or paper copy of your medical record maintained by the Facility. We will provide a copy or a summary of your protected health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
  • You can ask us to correct your medical record if you believe that it incorrect or incomplete. We may say “no” to your request, but we will explain the reason for our denial within 60 days of receipt of your request.
  • You can ask us to contact you in a specific way (for example, via cell phone) or to send mail to a different address. We will agree to all reasonable requests.
  • You can ask us not to use or share certain protected health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 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 our operations with your health insurer. We will honor the request unless a law requires that we disclose the information.
  • You can ask for a list (accounting) of the times we have shared your protected health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • You have the right to file a complaint if you believe your privacy rights have been violated. You can contact the Facility’s Privacy Officer using the information on page 1 or you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.