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.
For the purposes of this notice, the term “you or your” means the individual resident or recipient of services or the individuals legal guardian or legal representative as applicable.
Understanding your records/information
Your record contains information regarding your health, examinations, diagnoses, treatments, test results, and habilitation plan. This information is referred to as your central file and serves as a:
- Basis for planning your care and treatment
- Means of communicating among many professionals who contribute to your care
- Legal document describing the care you receive
- Means by which you or a third party payer can verify that services billed were actually received
- Tool in educating other professionals about you
- Source of data for research
- Source of information for regulatory officials who oversee the delivery of health care in the United States
- Source of data for facility planning and marketing
- Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how this information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your information, and make more informed decisions when authorizing disclosure to others.
- Our responsibilities
- Our agency is required to:
- Maintain privacy of your information
- Provide you with a notice as to our legal duties and privacy practices with respect to information we collected and maintain about you
- Abide by the terms of this notice
- Notify you if we are unable to agree to a requested restriction
- Accommodate reasonable requests you may have to communicate information by alternative means or at alternative locations
We reserve the right to change our practices and to make the new provisions effective for all protected information we maintain. Should our information practices change, we will notify you.
We will not use or disclose your information without your authorization except as described in this notice.
How we will use or disclose your information
1. Treatment: We will use your information for treatment, both health and habilitative treatment. For example, information obtained by a QMRP (Qualified Mental health Professional), nurse, physician, or other member of the interdisciplinary team will be recorded in your record and used to determine the course of treatment that should work best for you. These professionals will document in your record their findings, recommendations, and plan. The other team members will then record the actions taken and their observations. In that way these professionals will know how you are responding to your habilitation plan. We will also provide subsequent healthcare providers (such as: hospitals, doctors, laboratories, and various therapists like physical, speech, occupational, psychological) with copies of various pertinent reports or information that should assist them in treating you.
2. Payment: We will use your health information for payment. For example, a bill may be sent to you or a third party payor, including Medicaid and Medicare. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
3. Agency Operations: We will use your information for regular agency operations. For example, members of the staff or committees may use your information to monitor the care you are receiving, and the outcomes you achieve. This information will then be used in an effort to improve the quality of services we provide.
4. Business Associates: There are some services provided in our organization through contracts with business associates. Examples include accountants, consultants (social worker, psychologist, dietician, pharmacist, therapists, etc.) and attorneys. When these services are contracted, we may disclose your information to our business associates so that they can perform the job we’ve asked them to do. To protect your information, however, we require the business associates to appropriately safeguard your information.
5. Directory/Marketing: Unless you notify us that you object, we may use your name, location, picture, and general information for our directory, newsletters, website, general announcements, or other marketing purposes. For example, John Doe, who lives at Colnon-Wild House received a gold medal in Special Olympics, Resident of the Month postings, your name in the house or next to your bedroom door to help you identify your room, through the paging system, or to make general celebratory announcements.
6. Notification: Unless you notify us that you object, we may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your care, of your location, or general condition. If we are unable to reach your family member or representative, then we may leave a message for them at the phone number they have provided us, e.g., on an answering machine.
7. Communication with family: Professionals involved in your care, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, information relevant to that person’s involvement in your care or payment related to your care.
8. Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
9. Funeral Directors: We may disclose health information to funeral directors and coroners to carry out their duties consistent with the law.
10. Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in procurement, banking, or transplantation of organs for the purpose of tissue donation or transplant.
11. Governmental regulatory agencies: We may disclose your information relative to that agency as required for treatment, safety, health, licensure, certification, or accreditation. For example, the designated pre-admission screening agency for transfer among our residential facilities, the Food and Drug Administration if adverse affects to products are experienced by you, or Public Health for licensure surveys or to report or control disease, or law enforcement if a criminal investigation is warranted or by subpoena, appropriate authorities to report abuse or neglect, or a third party for accreditation purposes as required by the licensing agency.
12. Serious threat to health, safety, or medical emergency: We may disclose your information in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public. This disclosure can only be made to the person who is able to help prevent the threat. In the case of a medical emergency, we may disclose your information to the treating facility or person.
13. Workers’ Compensation: We may disclose your information as authorized by workers’ compensation laws or other similar programs that provide benefits for work related injuries or illness.
14. Disclosures required by HIPAA privacy rule: We may use and disclose your information to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA privacy rule.
Your information rights
Although your central file is the physical property of this agency, the information in your central file belongs to you. You have the following rights:
You may request that we not use or disclose your information for a particular reason related to treatment, payment, the agency’s general operations, and/or to a particular family member, other relative, or close personal friend. We ask that such requests be made in writing and submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954. We will attempt to accommodate all reasonable requests.
Although we will consider your request, please be aware that we are under no obligation to accept it or abide by it. The person making the request shall be notified of the outcome of the request within 30 days of receipt of the request. For more information about this right see 45 Code of Federal Regulations (CFR) 164.522(a); also see HIPAA Policy #7.
If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your information, you may request that we provide you with such information by alternative means or at alternative locations. Such requests must be made in writing and submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954. We will attempt to accommodate all reasonable requests. Also, see HIPAA Policy #8.
You may request to inspect and/or obtain copies of your information about you. Such requests must be made in writing and submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954.Such requests shall be acted upon within 30 days of receiving the request. A denial of this request shall be made in writing, approvals shall be made verbally. If you request copies, we may charge you a reasonable fee. For more information about this right see CFR 164.524, also see HIPAA Policy #5.
If you believe that any information in your record is incorrect or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. Such requests must be submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954. Also, see HIPAA Policy #4.
You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed six years). Requests must be made in writing and submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954. Please note that an accounting will not apply to any of the following types of disclosures: disclosures made for the purposes of treatment, payment, or operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes. You will not be charged for your first accounting request in any twelve month period. However, for any requests that you make thereafter, you may be charged a reasonable, cost based fee. For more information about this right see CFR 164.528; also see HIPAA Policy #6.
You have the right to obtain a paper copy of our Notice of Privacy Practices upon request. Requests can be made by contacting the Records Secretary either verbally or in writing.
You may revoke an authorization to use of disclose information, except to the extent that action has already been taken. Such a request must be made in writing and submitted to: Good Shepherd Manor Attn: Records Secretary, PO Box 260 Momence IL 60954. Also, see HIPAA Policy #7.
For more information or to report a problem
If you have any questions or would like additional information you may contact the Administrator at Good Shepherd Manor by calling (815) 472-3700.
If you believe your rights have been violated, you may file a complaint with the us. These complaints must be filed in writing When completed, this should be returned to the Administrator. You may also file a complaint with the secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint.