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.
PHNJ, LLC d/b/a Memory Care Living (“MCL”) is required by law to maintain the privacy of your medical information and to provide you with this notice so you will understand how we may use or share your medical information and MCL’s legal duties and privacy practices relative to your medical information. MCL is required to follow the terms of the notice currently in effect, and will not use or share your information other than as described herein unless you tell us we can in writing. If a breach occurs that may have comprised the privacy or security of your information, we will let you know promptly.
Following your receipt of this notice, please sign, date and return it to Julie Becher. If you have any questions about this notice, please contact Julie Becher at 38 North Central Ave., Ramsey, New Jersey 07446, (201) 368-7070 and email@example.com. A copy of this Notice will be posted on MCL’s website, www.memorycareliving.com and is available at our office and upon request.
UNDERSTANDING YOUR HEALTH AND MEDICAL RECORD INFORMATION
Every time you access or receive services from a MCL site, documentation in your health/medical record is made. Typically, this record contains information about your condition and the treatment that we provide. We use and disclose this information to:
- Plan your care and treatment
- Document the care you received
- Educate health professionals
- Provide information for medical research
- Provide data for MCL planning
- Communicate with other health professionals involved in your care
- Provide a means by which an insurance company can verify and pay for services
- Provide information to public health officials
- Evaluate and improve the care we provide
HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe the ways we may use and disclose your medical information. We are unable to describe every possible way that we may use or disclose medical information under each category below. However, all of the ways we are permitted or required to use and disclose information will fall into one of the following categories:
For Treatment. We may use medical information about you to provide you with medical treatment. We may disclose medical information about you to MCL personnel, as well as to doctors, nurses, therapists or other individuals who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know that you have diabetes because diabetes may slow the healing process. The doctor may also need to involve the dietitian, the pharmacist and therapist in your treatment plan. Different departments of MCL may share medical information about you in order to coordinate your care and provide you with medication, lab work and x-rays. We may also disclose medical information about you to people outside of MCL who may be involved in your medical care after you leave our residence. This may include visiting nurses that provide care in your home.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at MCL may be billed to you, an insurance company or a third party. For example, in order to be paid, we may need to share information with your long term care plan about services that MCL provided to you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose medical information about you for health care operations. This is necessary to ensure that all of our residents receive quality care. For example, we may use medical information to review our services for quality improvement activities. We may combine medical information about groups of MCL residents to evaluate our programs. We may also disclose information to doctors, nurses, therapists and other MCL personnel for review and learning purposes. We may remove information that identifies you so others may see it to study health care and health care delivery without learning the identities of residents.
OTHER ALLOWABLE USES OF YOUR MEDICAL INFORMATION
Business Associates. There are some services provided in our organization through contracts with business associates. Examples include, but are not limited to, outside attorneys and a copy service we use when making copies of your health record. When we contract with a business associate to provide these services, we may disclose your medical information so they can perform the job we have asked them to do. We do require that the business associate appropriately safeguard your information.
Directory Information. Unless you notify us that you object, we will use your name, location in the facility and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the condition of all residents who received one medication to those who received another for the same condition. A special approval process evaluates a proposed research project before it is implemented. Before we use or disclose your medical information for research, the project will have been approved through this process. We may, however, disclose medical information about you to people preparing to conduct a research study so long as the medical information they review does not leave the MCL premises.
Health Care Benefits and Reminders. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Workers’ Compensation. We may disclose medical information to the extent necessary to comply with laws relating to workers compensation or other similar programs. These programs provide benefits for work-related illness or injuries.
Reporting. Federal and state laws may require or permit MCL to disclose certain medical information related to the following:
- Public health risks:
* Prevention or control of disease, injury or disability.
* Reporting births and deaths.
* Reporting child abuse or neglect.
* Reporting reactions to medications or problems with products.
* Notifying people of product recalls.
* Notifying persons who may have been exposed to a disease.
* Reporting abuse, neglect or domestic violence: Notifying the appropriate government agency if we believe a resident has been the victim of abuse, neglect or domestic violence.
* Health oversight: We may disclose medical information to a health oversight agency for activities such as audits, investigations, inspections and licensure.
* Judicial and Administrative proceedings: If you or your residency is the subject of a lawsuit or dispute, we may disclose medical information about you in response to a court, arbitration or administrative order, subpoena, discovery request, or other lawful process.
Law Enforcement. We may disclose your medical information for law enforcement purposes as required by law or in response to a valid subpoena.
Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a friend or family member who is involved in your care and your designated responsible party. We may also give information to someone who helps pay for your care. We will only disclose the information, which is directly relevant to the person’s involvement in your care, or payment related to your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. In addition, as a condition of residency in a MCL residence, you must designate a responsible party who will be afforded access to your health record in order to consent to care, make payment or otherwise act on your behalf.
Funeral Directors, Medical Examiners and Coroners. We may disclose medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also disclose medical information to funeral directors as necessary.
Organ and Tissue Donation. If you are an organ donor, we may disclose medical information to organizations that handle organ procurement to facilitate donation and transplantation.
As Required by Law. MCL may use or disclose medical information if the use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of the law.
MCL may, in accordance with the law, disclose medical information that it believes in good faith is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or public. MCL would disclose such information to a person reasonably able to prevent or lessen the serious and imminent threat.
Specialized Government Functions: MCL may use or disclose medical information for specialized government functions such as to authorized federal officials so that they can provide protection to the U.S. President, other authorized persons or foreign heads of state, or to conduct special investigations; to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law, and if you are a member of the armed forces, we may disclose your information to the appropriate military authority.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization and permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written permission. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you. You also will be unable to revoke written authorization to disclose medical information that you gave as a condition of obtaining insurance coverage where the law allows the insurer to contest a claim under the policy or the policy itself. We will not share your information for marketing purposes or sale of your information without your prior written authorization and permission.
YOUR MEDICAL INFORMATION RIGHTS
Although your health record is the physical property of MCL, the information in your health record belongs to you. You have the following rights:
- Right to Request Restrictions.
You may request that we not use or disclose your medical information for a particular reason related to treatment, payment, or health care operations or that we not disclose medical information to a family member or other specific relative or close friend involved in your care. If we are unable to agree to a requested restriction, for instance if it would affect your care, we are not required to comply with the request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. If you pay for a service 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, unless applicable law requires that the information be shared.
You must submit your request in writing to Julie Becher. In your request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, for example, disclosures to your spouse.
- Right to Request Alternative Locations and Alternative Means.
You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location. For example, you may ask that we contact you via mail to a post office box.
You must submit your request in writing to Julie Becher. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
- Right to Inspect and Copy.
With some exceptions, you have the right to review and copy your medical information.
You must submit your request in writing to Julie Becher. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
- Right to Amend.
If you believe that any medical information in your records is incorrect or if you believe that important information is missing, you may request that we amend the existing information or add the missing information. We may deny your request for an amendment if it is not in writing or does not specify in what way the information is incorrect or incomplete. In addition, we may deny your request if you ask us to amend information that was not created by us, is not part of the medical information kept by MCL, or is accurate and complete. If we deny your request, usually within 60 days, we will tell you why in writing.
You must submit your request in writing to Julie Becher. In addition, you must provide a reason for your request.
- Right to an Accounting of Disclosures.
You may request that we provide you with a written accounting of all disclosures made by us during a certain time period. This is a list of certain disclosures we made of your medical information. It will not include certain disclosures such as those made for treatment, payment or healthcare operations purposes.
You must submit your request in writing to Julie Becher. Your request must state a time period, which may not be longer than 6 years from the date the request is submitted. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists during any 12-month period, we may charge you for the costs of providing the list.
- Right to Choose Someone to Act for You.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
Right to a Notice of a Breach.
You have a right to be notified upon a breach of any of your protected health information.
- Right to Revoke Authorization.
If we ask or you provide us with an authorization to use or disclose your information, you can cancel that authorization at any time.
You must submit your request in writing to Julie Becher. You request will not affect any information that has already been shared.
- Right to a Paper Copy of This Notice.
You have the right to obtain a paper copy of our Notice of Information Practices upon request, even if you agreed to receive the notice electronically.
You must submit your request in writing to Julie Becher.
- Sharing Information with Family and Friends.
You have the right and choice to share information with your family, close friends, or others involved in your care, to share information during a disaster relief situation, and include your information in a resident directory. If you are unable to communicate to us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest, and we may also share your information when needed to lessen a serious and imminent threat to health or safety.
You have the right and choice to tell us to contact you for fundraising efforts. We may contact you for fundraising efforts, but you can tell us not to contact you again. Treatment and payment will not be conditioned upon your choice as to fundraising communications.
- Written Authorization Required.
We will not share your information for marketing purposes and we will not sell your information without first obtaining written authorization and permission from you. Similarly, we will never share any substance abuse treatment records, HIV information, genetic information, or venereal disease information without your written authorization and permission.
- Psychotherapy Notes.
We do not create or maintain psychotherapy notes at MCL.
If you believe your privacy rights have been violated, you may file a complaint with MCL or with the Secretary of the Department of Health and Human Services. To file a complaint with MCL, contact Julie Becher at the following telephone number: (201) 368-7070. All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
CHANGES TO THIS NOTICE
MCL reserves the right to change its privacy practices as set forth in this notice and to make the new provisions effective for all medical information that MCL maintains. If material changes are made to this notice, the notice will contain an effective date of the revisions and copies can be obtained by contacting Julie Becher. This Notice, and any revisions thereto, will also be made available on the MCL web site, www.memorycareliving.com, at our office, and upon request.
This Notice is Effective as of: June 8, 2017
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
Name of Resident/Patient (please print)
_________________________________ Name of Responsible Party (please print)
Resident/Patient or Responsible Party Signature