ORCHARD MANOR’S
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.
USE
AND DISCLOSURE OF HEALTH INFORMATION
Orchard Manor may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Facility has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES
UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND
DISCLOSED:
To
Provide Treatment. Orchard
Manor 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.
For example, physicians involved in your care will need information about
your symptoms in order to prescribe appropriate medications.
To
Obtain Payment. Orchard Manor may include your health information in
invoices to collect payment from third parties for the care you may receive from
Orchard Manor. For example, Orchard
Manor may be required by your health insurer to provide information regarding
your health care status so that the insurer will reimburse you or Orchard Manor.
To Conduct Health Care Operations. Orchard Manor may use and disclose health information for its own operations in order to facilitate the function of Facility and as necessary to provide quality care to all of Orchard Manor’s residents. Health care operations include activities such as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol development, case management and care coordination.
- Contacting health care providers and residents with information about treatment alternatives and other related functions that do not include treatment.
- Professional review and performance evaluation.
- Training programs including those in which students, trainees or practitioners in health care learn under supervision.
- Training of non-health care professionals.
- Accreditation, certification, licensing or credentialing activities.
- Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of Facility.
- Fundraising for the benefit of Facility and certain marketing activities.
- Digital photograph in resident medical record for identification proposes.
For example, Orchard
Manor may use your health information to evaluate its staff performance, combine
your health information with other Orchard Manor residents in evaluating how to
more effectively serve all of Orchard manor's residents, disclose your health
information to Facility staff and contracted personnel for training purposes,
use your health information to contact you or your family as part of general
fundraising and community information mailings (unless you tell us you do not
want to be contacted).
For the Facility Directory. Orchard Manor may disclose certain information about you including your name, your general health status, your religious affiliation and where you are located in a facility directory while you are in Orchard Manor. Orchard Manor may disclose this information to people who ask for you by name. However, religious affiliation will only be disclosed to clergy. If you do not want Orchard Manor to include your information in the directory, you must notify Donna Haines at 608-723-2113.
For Fundraising Activities. Orchard Manor may use information about you including your name, address and telephone number to contact you or your family to raise money for Orchard Manor. If you do not want Orchard Manor to contact you or your family, you must notify Donna Haines at 608-723-2113 and indicate that you do not wish to be contacted.
For Treatment Alternatives. Orchard Manor may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
THE
FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH
YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED WITHOUT YOUR WRITTEN
AUTHORIZATION:
When Legally Required. Orchard Manor will disclose your health information when it is required to do so by any Federal, State or local law.
When There Are Risks to Public Health. Orchard Manor may disclose your health information for the following public activities and purposes:
- To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
- To report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
- To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
- To an employer about an individual who is a member of the workforce as legally required.
To Report Abuse, Neglect Or Domestic Violence. Orchard Manor is allowed to notify government authorities if Orchard Manor believes a resident is the victim of abuse, neglect or domestic violence. Orchard Manor will make this disclosure only when specifically required or authorized by law or when the resident agrees to the disclosure.
To Conduct Health Oversight Activities. Orchard Manor may disclose your health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Orchard Manor, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits.
In
Connection With Judicial And Administrative Proceedings.
As permitted or required by State law, Orchard Manor may disclose your
health information in the course of any judicial or administrative proceeding in
response to an order of a court or administrative tribunal as expressly
authorized by such order or in response to a subpoena, discovery request or
other lawful process, but only when Orchard Manor makes reasonable efforts to
either notify you about the request or to obtain an order protecting your health
information.
For Law Enforcement Purposes. As permitted or required by State law, Orchard Manor may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
To Coroners And Medical Examiners. Orchard Manor may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors. Orchard Manor may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Orchard Manor may disclose your health information prior to and in reasonable anticipation, of your death.
For Organ, Eye Or Tissue Donation. Orchard Manor may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.
For Research Purposes. Orchard Manor may, under very select circumstances, use your health information for research. Before Orchard Manor discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Orchard Manor will almost always request your written authorization before granting access to your individually identifiable health information.
In
the Event of A Serious Threat To Health Or Safety.
Orchard Manor may, consistent with applicable law and ethical standards
of conduct, disclose your health information if Orchard Manor, in good faith,
believes that such disclosure is necessary to prevent or lessen a serious and
imminent threat to your health or safety or to the health and safety of the
public.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize Orchard Manor to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker's Compensation. Orchard Manor may release your health information for worker's compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, Orchard Manor will not disclose your health information other than with your written authorization. If you or your representative authorizes Orchard Manor to use or disclose your health information, you may revoke that authorization in writing at any time.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that Orchard Manor maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Orchard Manor's disclosure of your health information to someone who is involved in your care or the payment of your care. However, Facility is not required to agree to your request. If you wish to make a request for restrictions, please contact Donna Haines at 608-723-2113.
Right to Receive Confidential Communications. You have the right to request that Orchard Manor communicate with you in a certain way. For example, you may ask that Orchard Manor only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Donna Haines at 608-723-2113. Orchard Manor will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Donna Haines at 608-723-2113. If you request a copy of your health information, Orchard Manor may charge a reasonable fee for copying and assembling costs associated with your request.
Right to Amend Your Health Information. You or your representative have the right to request that Orchard Manor amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Orchard Manor. A request for an amendment of records must be made in writing to Donna Haines at 608-723-2113. Orchard Manor may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Orchard Manor, if the records you are requesting are not part of Orchard Manor's records, 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 Orchard Manor, the records containing your health information are accurate and complete.
Right
to an Accounting. You or
your representative have the right to request an accounting of disclosures of
your health information made by Orchard Manor for any reason other than for
treatment, payment or health operations. The
request for an accounting must be made in writing to Donna Haines at
608-723-2113.
The request should specify the time period for the accounting starting on
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.
To obtain a separate paper copy, please contact Donna Haines at
608-723-2113.
DUTIES OF FACILITY
Orchard Manor
is required by law to maintain the privacy of your health information and to
provide to you and your representative this Notice of its duties and privacy
practices. Orchard Manor is required
to abide by the terms of this Notice as may be amended from time to time.
Orchard Manor reserves the right to change the terms of its Notice and to
make the new Notice provisions effective for all health information that it
maintains. If Orchard Manor changes
its Notice, Orchard Manor will provide a copy of the revised Notice to you or
your appointed representative. You
or your representative have the right to express complaints to Facility and to
the Secretary of Health and Human Services if you or your representative believe
that your privacy rights have been violated.
Any complaints to Orchard Manor should be made in writing to Donna Haines
at 608-723-2113 or by writing to her at Orchard Manor, 8800 Hwy 61,
CONTACT PERSON
Orchard Manor
has designated the Donna Haines as its contact person for all issues regarding
resident privacy and your rights under the Federal privacy standards.
You may contact this person at 608-723-2113.
EFFECTIVE DATE
This Notice is effective
IF
YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT Donna Haines at
608-723-2113 extension 164.