THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures for Treatment, Payment and Health Operations,
Based on Your Consent

We will use your health information for treatment. For example, information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

We will also provide your primary care physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you here or if you are transferred from this facility to another setting. We may also send relevant portions of your medical record to specialists to whom you are being referred for care, or to physicians whom your providers here may want to consult on a care issue.

We may use or disclose your PHI for purposes of contacting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you. For example, many residents at Maristhill are members of the “Evercare” insurance program, which provides enhanced Medicare benefits for long-term care residents.

We will use your health information for regular health operations. For example, members of the healthcare staff or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

We provide some services through business associates, who are independent professionals using patient health information provided by us in order to perform certain services. Examples include laboratory radiology, oxygen, pharmacy, and rehabilitation services. When these services are contracted, we may disclose your health information to our business associate so they may perform the job we have asked them to do and bill you or your insurer for services rendered. Other examples of business associates include JCAHO (Joint Commission on Accreditation of healthcare Organizations), AccuMeasure, the transmittal intermediary for JCAHO, our medical records consultant, and ACS, our fiscal intermediary. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Uses and Disclosures We May Make Unless You Object
Unless you notify us that you object, we will use your name, location in the facility, and personal telephone number, if applicable, in our facility director. This information may be provided to members of your family, friends, members of the clergy and to other people who ask for you by name.

Unless you notify us that you object, we may use your name and birthday in the resident monthly newsletter and calendar posting.

Unless you notify us that you object, health professionals, using their best judgment, may disclose to your designated responsible party or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

We may use or disclose your health information in connection with limited marketing or fund-raising communication permitted under the Federal Privacy Rules. Any such communication addressed to you will contain instructions describing how you may decline to receive further such communications.

Uses and Disclosures Permitted Without Consent, Authorization, or Opportunity to Object
Maristhill may use or disclose protected health information without your written consent, authorization, or opportunity to object in the following instances:

• when required by law
• to state and federal public health authorities
• to government authorities, including social service or protective services agencies authorized by law to receive reports of abuse, neglect, or domestic violence
• to government health oversight agencies for oversight activities authorized by law, such as the state and federal Departments of Health & Human Services, Medicare/Medicaid Peer Review Organizations (PRO’s), state Boards of Medicine, Nursing, and Pharmacy, and other licensing authorities
• when required by court order or other lawful process in a judicial or administrative proceeding
• to law enforcement officials for certain law enforcement purposes
• to coroners, medical examiners, or funeral directors in order to carry out their duties as required by law
• to organ procurement organizations
• for research approved by an Institutional Review Board or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information
• when required to avert a serious threat to health or safety
• when requested for certain specialized government functions authorized by law, including military and other situations
• as authorized by law in connection with workers’ compensation programs
• to any law enforcement official or correctional institution if you are inmate or under custody of a law enforcement official

Other Uses and Disclosures
We may use or disclose your PHI for purposes other than treatment, payment of health care operations or as described in this document and for purposes which are not required by law only after receiving your written authorization. You have the right to revoke a written authorization and we will no longer use or disclose your PHI for the purposes identified in the authorization. You understand that we are unable to retrieve any disclosures which we may have made pursuant to your authorization prior to its revocation. Some examples of uses or disclosures that may require your written authorization include a request to provide your PHI to an attorney for use in a civil litigation claim, or a request to provide your PHI for purposes of including you on a mailing list.

Right to request confidential communications
You have the right to request that we communicate with you about your health care in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Director of Social Services. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how and/or where you wish to be contacted.

Right to inspect and copy
You have the right to inspect and copy PHI that may be used to make decisions about your care. Generally, this includes medical and billing records but does not include psychotherapy notes. Please refer to the handout, “Maristhill Nursing & Rehabilitation Center Resident Rights” for further information. We may deny your request to inspect and copy your PHI in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional selected by our facility will review your request and the denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of this review.

Right to an accounting of disclosures
You have the right to request an accounting of the disclosures which we have made of your health information. This accounting will not include disclosures of PHI that we made for purposes of treatment, payment, or health care operations or for disclosures we made that you authorized us to make. To request an accounting of disclosures, you must submit your request in writing to the Director of Social Services. Your request must state a time period which may not be longer than six (6) years prior to the date of your request and may not include dates before April 14, 2003. Your request should indicate in what form you want to receive the accounting (for example, on paper or via electronic means). The first accounting that you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to request an amendment
If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our facility. To request and amendment, your request must be made in writing and submitted to the Director of Social Services. In addition, you must provide us with a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that

1. was not created by us, unless the person or entity that created the information is not longer available to make the amendment
2. is not part of the PHI kept by or for our facility
3. is not part of the information which you would be permitted to inspect and copy
4. is accurate and complete

Our Responsibilities
Maristhill is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of the notice currently in effect. We reserve the right to change the terms of the notice and to make the new notice provisions effective for all protected health information. We will post all revised notices and provide you with a paper copy of revisions upon your request.

For More Information or to Report a Problem
If you have questions, you may contact the Privacy Officer, who is the Director of Social Services at Maristhill Nursing & Rehabilitation Center, 66 Newton Street, Waltham, MA, 02453, #781-893-0240. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer at the above address, or with the Secretary of Health and Human Services, 200 Independence Avenue, SW, Washington, DC, 20201 or by sending HHS an email at HHS.Mail@hhs.gov. There will be no retaliation for filing a complaint.

Effective Date: April 14, 2003