BAPTIST COMMUNITY SERVICES

Ware Living Center 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. We respect the privacy of your personal health information and are committed to maintaining our patient’s confidentiality. This Notice applies to all information and records related to your care that our facility has received or created. It extends to information received or created by our employees, staff, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your personal health information.

We are required by law to:

• maintain the privacy of your protected health information;
• provide to you this detailed Notice of our legal duties and privacy practices relating to your personal health information; and
• abide by the terms of the Notice that are currently in effect.

I. WE MAY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

We will use and disclose your personal health information for purposes of treatment, payment, and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories.

For Treatment. We will use and disclose your personal health information in providing you with treatment and services. We may disclose your personal health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, and physical therapists. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose personal health information to individuals who will be involved in your care after you leave the facility.

For Payment. We may use and disclose your personal health information so that we can bill and receive payment for the treatment and services you receive at the facility. For billing and payment purposes, we may disclose your personal health information to your representative, 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 a proposed treatment or service.

For Health Care Operations. We may use and disclose your personal health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use personal health information to evaluate our facility’s services, including the performance of our staff.

The uses and disclosures of your personal health information are essential to our ability to care for you.

I. WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES

Facility Directory. Unless you object, we will include certain limited information about you on our facility directory. This information may include your name, your location in the facility, and 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 your personal health information to a family member or close personal friend, including clergy, who is involved in your care.

Disaster Relief. We may disclose your personal health information to an organization assisting in a disaster relief effort.

As Required By Law. We will disclose your personal health information when required by law to do so.

Public Heath Activities. We may disclose your personal health information for public health activities. These activities may include, for example

• reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting child abuse or neglect;
• reporting to the federal Food and Drug Administration (FDA) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;
• 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 or
• for certain purposes involving workplace illness or injuries.

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 personal health information to notify a government authority if required or authorized by law, or if you agree to the report.

Health Oversight Activities. We may disclose your personal health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. We may disclose your personal 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 personal health information for certain law enforcement purposes, including

• as required by law to comply with reporting requirements;
• to comply with a court order, warrant, subpoena, summons, investigative demand or similar legal process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• when information is requested about the victim of a crime if the individual agrees or under other limited circumstances;
• to report information about a suspicious death;
• to provide information about criminal conduct occurring at the facility;
• to report information in emergency circumstances about a crime; or
• where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.

Research. We may allow personal health information of patients from our own facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your personal health information may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board, 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 personal 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

To Avert a Serious Threat to Health or Safety. We may use and disclose your personal health information when necessary to prevent a serious threat to your health or safety or the health and 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 personal health information as required by military command authorities. We may also use and disclose personal health information about foreign military personnel as required by the appropriate foreign military authority.

Workers’ Compensation. We may use or disclose your personal health information to comply with laws relating to workers’ compensation or similar programs.

National Security and Intelligence Activities; Protective Services for the President and Others. We may disclose personal health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.

Fundraising Activities. We may use certain personal heath information to contact you in an effort to raise money for the facility and its operations. We may disclose personal health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility. In doing so, we would only release contact information, such as your name, address and phone number and the dates you received treatment or services at the facility. You have the right to opt out of receiving fundraising communication.

Treatment Alternatives. We may use or disclose personal health information to inform you about treatment alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use or disclose personal health information to inform you about health-related benefits and services that may be of interest to you.

III. YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF PERSONAL HEALTH INFORMATION

We will use and disclose personal health information (other than as described in this Notice or required by law) only with your written Authorization. You may revoke your Authorization to use or disclose personal health information in writing, at any time. If you revoke your Authorization, we will no longer use or disclose your personal health information for the purposes covered by the Authorization, except where we have already relied on the Authorization.

IV. YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION

You have the following rights regarding your personal health information at the facility:

Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your personal health information for treatment, payment, or health care operations. You also have the right to restrict the personal health information we disclose about you to a family member, friend or other person who is involved in your care or the payment of your care.

We are not required to agree to your requested restriction (except that while you are competent you may restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

Right of Access to Personal Health Information. You have the right to inspect and obtain a copy of your medical or billing records or other written information that may be used to make decisions about your care subject to some limited exceptions. We may charge a reasonable fee for our costs in copying and mailing your requested information.

We may deny your request to inspect or receive copied in certain limited circumstances. If you are denied access to personal health information, in some cases you will have a right to request review of the denial. This review would be performed by a licensed health care professional designated by the facility who did not participate in the decision to deny.

Right to Request Amendment. You have the right to request the facility to amend any personal health information maintained by the facility for as long as the information is kept by or for the facility. You must make your request in writing and must state the reason for the requested amendment.

We may deny your request for amendment if the information

• was not created by the facility, unless the originator of the information is no longer available to act on our request;
• is not part of the personal health information maintained by or for the facility;
• is not part of the information to which you have a right of access; or
• 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.

Right to an Accounting of Disclosures. You have the right to request an “accounting” of our disclosures of your personal health information. This is a listing of certain disclosures of your personal health information made by the facility or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 14, 2003 that is within six years from the date of your request. An accounting will include, if requested: the disclosure date; the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; a brief statement of the purpose of the disclosure or a copy of the authorization or request; or certain summary information concerning multiple similar disclosures. The first accounting provided within a 12- month period will be free; for further requests, we may charge you our costs.

Right to direct an organization to transmit his or her PHI electronically to a third person.

Right to review or receive a copy of your electronic health records.

Right to restrict disclosure of PHI to a health plan if the healthcare item or service has been paid out of pocket and in full, unless the disclosure is required by law. A notation will be made in medical record.

Right to be notified following a breach of unsecured protected health information.

Right to the prohibition on the sale of PHI without the written authorization of an individual.

Right to the prohibition of the use and disclosure of psychotherapy notes, marketing, and the sale of PHI.

V. COMPLAINTS

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. To file a complaint with the facility, contact Robert Smith, Vice President Regulatory Affairs, 337-4144.

We will not retaliate against you if you file a complaint.

VI. 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 personal health information already received and maintained by the facility as well as for all personal health information we receive in the future. We will post a copy of the current Notice in the facility. In addition, we will provide a copy of the revised Notice to all patients by mail or hand delivery.

VII. FOR FURTHER INFORMATION

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Robert Smith, Vice President, 806-337-4144.

VIII. YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION

You have the following rights regarding your personal health information at the facility:

• Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your personal health information for treatment, payment or health care operations. You also have the right to restrict the personal 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 unless 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.
• Right of 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. If you request copies of the records, we must provide you with copies within 2 days of that request. We may charge a reasonable fee for our costs in copying and mailing your requested information.

Notice of nondiscrimination

Baptist Community Services dba Ware Living Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Baptist Community Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Baptist Community Services:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact Michelle Stillman, Administrator.

If you believe that Baptist Community Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Michelle Stillman – Administrator, 400 W. 14th, Amarillo, Texas 79101, (806) 337-4000, Fax: (806) 337-5184, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Michelle Stillman, Administrator, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.