"SMILES... from the moment I arrived at Evergreen until I left 12 days later, all of the staff always had SMILES on their faces!"Phyllis G. | Stafford Springs
|Effective Date: April 14, 2003|
THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
THIS NOTICE APPLIES TO EVERGREEN HEALTH CARE CENTER AND TO ANY HEALTH CARE PROFESSIONAL WHO TREATS YOU IN OUR FACILITY, INCLUDING MEMBERS OF OUR MEDICAL STAFF.
PLEASE REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of your health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; and to abide by the terms of the Notice that are currently in effect.
I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
The following lists various ways in which we may use or disclose your health information for purposes of treatment, payment and health care operations.
For Treatment: We will use and disclose your health information in providing you with treatment and services and coordinating your care and may disclose information to other providers involved in your care. Your health information may be used by doctors involved in your care and by nurses and nurse aides as well as by physical therapists, pharmacists, suppliers of medical equipment or other persons involved in your care. For example, we will contact your physician to discuss your plan of care.
For Payment: We may use and disclose your health information for billing and payment purposes. We may disclose your health information to your representative, or to an insurance or managed care company, Medicare, Medicaid or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for services that will be provided to you.
For Health Care Operations: We may use and disclose your health information as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor our quality of care. We may disclose your health information to another entity with which you have or had a relationship if that entity requests your information for certain of its health care operations or health care fraud and abuse detection or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services.
II. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
The following lists various ways in which we may use or disclose your health information.
Facility Directory: Unless you object, we will include certain limited information about you in our facility directory. This information may include your name, your location in the facility, your general condition and your religious affiliation. Our directory does not include specific medical information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.
Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose health information about you to a family member, close personal friend or other person you identify, including clergy, who is involved in your care.
Emergencies: We may use or disclose your health information as necessary in emergency treatment situations.
As Required By Law: We may use or disclose your health information when required by law to do so.
Business Associates: We may disclose your protected health information to a contractor or business associate who needs the information to perform services for the facility. Our business associates are committed to preserving the confidentiality of this information.
Public Health Activities: We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting abuse or neglect; or reporting deaths.
Reporting Victims of Abuse, Neglect or Domestic Violence: If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your health information to notify a government authority, if authorized by law or if you agree to the report.
Health Oversight Activities: We may disclose your health information to a health oversight Facility for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system.
To Avert 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 health information, limiting disclosures to someone able to help lessen or prevent the threatened harm.
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. Efforts must be made to contact you about the request or to obtain an order or agreement protecting the information.
Law Enforcement: We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.
Research: We may use or disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.
Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations: We may release your health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.
Disaster Relief: We may disclose health information about you to a disaster relief organization.
Military, Veterans and other Specific Government Functions: If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.
Workers' Compensation: We may use or disclose your health information to comply with laws relating to workers' compensation or similar programs.
Inmates/Law Enforcement Custody: If you are under the custody of a law enforcement official or a correctional institution, we may disclose your health information to the institution or official for certain purposes, including the health and safety of you and others.
Fundraising Activities: We may use certain limited information to contact you in an effort to raise funds for the Facility and its operations.
Appointment Reminders: We may use or disclose health information to remind you about appointments.
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.
III. USES AND DISCLOSURES WITH YOUR AUTHORIZATION
Except as described in this Notice, we will use and disclose your health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.
IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Listed below are your rights regarding your health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to the Facility. At your request, the Facility will supply you with the appropriate form to complete. You have the right to:
Request Restrictions: You have the right to request restrictions on our use or disclosure of your health information for treatment, payment or health-care operations. You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.
We are required to agree to your requested restriction with respect to release of your health information to any individual outside the Facility unless you are being transferred to another health care institution, the release of records is required by law, third-party payment or to provide you with emergency care.
Access to Personal Health Information: You have the right to request, either orally or in writing, your medical or billing records or other written information that may be used to make decisions about your care. We must allow you to inspect your records within 24 hours of your request (excluding weekends and holidays). If you request copies of the records, we must provide you with copies within 2 working days of that request. We may charge a reasonable fee consistent with State law for our costs in copying and mailing your requested information.
Request Amendment: You have the right to request amendment of your health information maintained by the Facility for as long as the information is kept by or for the Facility. Your request must be made in writing and must state the reason for the requested amendment.
We may deny your request for amendment if the information (a) was not created by the Facility, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for the Facility; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by the Facility.
If we deny your request for amendment, we will give you a written denial, including the reasons for the denial and the right to submit a written statement disagreeing with the denial.
Request 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 the Facility or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosure made pursuant to your Authorization, and certain other exceptions.
To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.
Request 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. In addition, you may obtain a copy of this Notice at our website, www.johnsonhealthnetwork.com/evergreen.htm.
Request Confidential Communications: You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.
V. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION
For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. Except as provided below and as specifically permitted or required under state or federal law, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization.
Psychiatric information: If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed. Certain limited information may be disclosed for payment purposes.
HIV-related information: HIV-related information may be disclosed for purposes of treatment or payment.
Substance abuse treatment: If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies.
VI. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT
If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Evergreen's Admissions Representative at 860-684-8710.
If you believe that your privacy rights have been violated, you may file a complaint in writing with the Facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint.
To file a complaint with the Facility, contact Kristen Chadderton, Admissions Representative, at 860-684-8710.
VII. CHANGES TO THIS NOTICE
We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by the Facility as well as for all health information we receive in the future. We will post a copy of the current Notice in the Facility, and we will provide a copy of any revised Notice upon request.