SHEBOYGAN SENIOR COMMUNITY, INC.

 

  PRIVACY NOTICE

 

 

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.

 

Sheboygan Senior Community, Inc. is required by law to maintain the privacy of your health information, abide by the terms of this Notice, and to provide to you and your representative this Notice of its duties and privacy practices concerning your personal health information. Sheboygan Senior Community, Inc. reserves the right to change the terms of its Notice. These changes to the Privacy Notice will apply to all health information we maintain. If we change our privacy practices, you or your appointed representative will receive a copy of the revised notice.

 

The following is a summary of the circumstances and purposes for which your health information may be used and disclosed:

 

  • 1. To Provide Treatment. We may use your health information to provide care to you and disclose your health information to others who provide care to you, such as your attending physician and other health care professionals who are involved in your care.

 

Sheboygan Senior Community, Inc. also may disclose your health care information to individuals outside of the Facility involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals.

 

  • 2. To Obtain Payment. We may be required to provide health information to collect payment from third parties for the care you may receive from the Sheboygan Senior Community, Inc.

 

In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis, and the treatment provided to you.

 

  • 3. To Conduct Health Care Operations. Sheboygan Senior Community, Inc. may use and disclose health information for its own health care operations to improve quality care to all the facility's residents. We may use and disclose your health information to tell you about or recommend possible treatment options that may be of interest to you.

 

For example: Sheboygan Senior Community, Inc. may use your health information to evaluate its staff performance, combine your health information with other  residents in evaluating how to more effectively serve all of the facility's residents, disclose your health information to facility staff and contracted personnel for training purposes. (Health care operations include activities such as: Quality assessment, protocol development, case management and care coordination, professional review and performance evaluation, training programs in which students, trainees or practitioners in health care learn under supervision, accreditation, certification licensing or credentialing activities, reviews and audits, business planning, development, management, fundraising and certain marketing activities)

 

  • 4. For Fundraising Activities. Sheboygan Senior Community, Inc. may use information about you including your name, address and telephone number to contact you or your family to raise money for the facility.

 

If you do not want Sheboygan Senior Community, Inc. to contact you or your family, you must notify Sheboygan Senior Community's Privacy Officer at (920) 458-2137.

 

  • 5. For the Facility Directory: Sheboygan Senior Community, Inc. may disclose certain information about you, including your name, birthdate, general health status, religious affiliation (religious affiliation will only be disclosed to clergy), and where you are located, in the facility directory while you are in the facility. We may disclose this information to people who ask for you by name.

 

If you do not want to have your information in the facility directory, you must notify Sheboygan Senior Community's Privacy Officer at (920) 458-2137.

 

Without your written authorization, we can use your health information for the following purposes:

 

  • 1. As Required or Permitted by Law. Sheboygan Senior Community, Inc. will disclose your health information when it is required to do so by any Federal, State or local law. Disclosures may be made to legal authorities, such as law enforcement officials, court officials, or government agencies.

 

For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.

 

  • 2. For Public Health Activities. We may be required to report your health information to authorities to help prevent or control disease, injury, or disability, or to an employer about an individual who is a member of the workforce as legally required. This may include using your medical record to report certain diseases, injuries, birth or death information, the conduct of public health surveillance, to report adverse events, product defects, to track products or enable product recalls, repairs and replacement and information of concern to the Food and Drug Administration.

 

  • 3. To Conduct Health Oversight Activities. Sheboygan Senior Community, Inc. may disclose your health information to authorities so they can monitor, investigate, inspect, discipline or license those who work in the health care system or for government benefit programs. We may not disclose your health information if you are the subject of an investigation and the investigation is not directly related to your receipt of health care of public benefits.

 

  • 4. For Activities Related to Death. Sheboygan Senior Community, Inc. may disclose your health information to coroners, medical examiners and funeral directors so they can carry out their duties related to your death, or in the case of funeral directors, to carry out funeral preparation activities.

 

  • 5. For Organ, Eye or Tissue Donation. Sheboygan Senior Community, Inc. may disclose your health information to individuals involved with obtaining, storing or transplanting organs, eyes or tissue for donation purposes.

 

  • 6. For Research. Under certain circumstances, and only after an extensive approval process, Sheboygan Senior Community, Inc. may use your health information for research purposes. Written authorization will almost always be requested before granting access to your individually identifiable health information.

 

  • 7. In the Event of a Serious Threat to Health or Safety. Sheboygan Senior Community, Inc. may, consistent with applicable law and ethical standards of conduct, disclose your health information if we, in good faith, believe that such release is necessary to prevent or minimize a serious and approaching threat to your health or safety or to the health or safety of the public.

 

  • 8. For Military, National Security, or Incarceration/Law Enforcement Custody. In certain circumstances the Federal regulations authorize Sheboygan Senior Community, Inc. to disclose your health information to facilitate specified government functions relating to military, veterans, national security and intelligence activities, or disclose to law enforcement officials for certain law enforcement purposes, including under certain circumstances, if you are a victim of a crime or in order to report a crime.

 

  • 9. For Worker's Compensation. Sheboygan Senior Community, Inc. may release your health information for worker's compensation or similar programs.

 

 

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

 

Other than is stated above, Sheboygan Senior Community, Inc. will not disclose your health information other than with your written authorization. If you sign an authorization form, you may withdraw your authorization at any time, provided your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to Sheboygan Senior Community, Inc., Privacy Officer, 930 North 6th Street, Sheboygan, WI 53081.

 

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

 

You have several rights with regard to your health information. If you wish to exercise any of the following rights, please contact Sheboygan Senior Community's Privacy Officer.

 

1. Right to Request Restrictions.You have the right to request restrictions on certain uses and disclosures of your health information. You may want to limit the health information provided to someone who is involved in your care or the payment of your care. However, Sheboygan Senior Community, Inc. is not required to agree to your request. 

 

  • 2. Right to Receive Confidential Communications. You have the right to request that Sheboygan Senior Community, Inc. communicate with you in a certain way, for example, that we conduct communications pertaining to your health information with you privately with no other family members present. You need not provide any reasons for your request and we will attempt to honor your reasonable requests for confidential communications.

 

  • 3. Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. If you request a copy of your health information, we may charge a reasonable fee for copying and assembling costs associated with your request.

 

  • 4. Right to Amend Your Health Information. If you believe your health information records are incorrect or incomplete, you or your representative has the right to request that we amend your records. This request may be made as long as the information is maintained by the facility. A request for amendment must be made in writing and include a reason for the amendment. The request may be denied if your health information records were not created by Sheboygan Senior Community, Inc., if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of the facility, the records containing your health information are accurate and complete.

 

  • 5. Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Sheboygan Senior Community, Inc. for certain purposes, which may include disclosures authorized by law and disclosures made for research. The request for an accounting should be made to Sheboygan Senior Community, Inc., Medical Records, 930 North 6 Street, Sheboygan WI 53081. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

 

  • 6. Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously.

 

  • 7. Complaint. If you or your representative believe your rights have been violated, you have the right to express complaints to Sheboygan Senior Community, Inc. and to the Secretary of Health and Human Services. To file a complaint with either entity, contact Sheboygan Senior Community, Inc., Privacy Officer, 930 North 6 Street, Sheboygan, WI 53081, (920) 458-2137. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

 

CONTACT PERSON

  

For all issues regarding resident privacy and your rights under the Federal privacy standards, you may contact Sheboygan Senior Community, Inc., Privacy Officer, 930 North 6th Street, Sheboygan WI 53081, (920) 458-2137.

 

EFFECTIVE DATE

 

This Notice is effective April 14, 2003.

 

 

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:

  

            Sheboygan Senior Community, Inc., Privacy Officer, 930 North 6th Street, Sheboygan WI  53081, (920) 458-2137.