Country Manor Campus

Effective Date: 4/14/2003

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

If you have questions about this notice, please contact the Facility Privacy Officer.

This notice applies to all records of your care generated by Country Manor.

Our Responsibilities

Country Manor has always been committed to protecting the confidentiality of your health information. We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. If you have any questions about the content of this notice, please contact the Privacy Officer. Country Manor will not use/disclose your health information without authorization, except as described below in this notice.

Uses and Disclosures

How we may use and disclose Health Information about you.

The following categories describe examples of the way we use and disclose health information:

Treatment: We may use health information about you to provide treatment and services to you. We may disclose health information about you to doctors, nurses, technicians, or other health care facilities who are involved in taking care of your health needs. For example: we may need to exchange information about your health with other current health care providers (such as hospitals, pharmacies, nursing facilities) in order to set an appropriate course of treatment to meet your needs. We may also provide a subsequent health care provider with copies of various reports that should assist in treating your health care needs.

Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or from 3rd parties. For example: we may need to provide your insurance company with information on the type of health care services and medications we are providing to you so that they will reimburse Country Manor for your treatment.

Health Care Operations: Members of our staff may use information in your health records to assess the care and outcomes in your case and others like it. The results can be used to improve the quality of services provided in our Facility. For example: we may combine the health information about many residents with the same health care needs in order to evaluate the effectiveness of certain treatment procedures.

We may also use and disclose health information:

To business associates we have contracted with to perform the agreed upon service and billing for it;
To remind you that you have a pending appointment for medical care;
To assess your satisfaction with our services;
To tell you about possible treatment alternatives;
To contact you as a part of fund raising efforts;
To inform Funeral Directors consistent with applicable law;
For Population based activities relating to improving health or reducing health care costs; and
For Fund Raising efforts
For conducting employee training programs.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include: Employee Health Care, Independent Accounting Services, and various Clinical Software Vendors. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do in order to facilitate the health care needs of our residents and employees. To protect your health information, we require the business associate to appropriately safeguard your information.

Directory: We may include certain limited information about you in our facility directory while you are a resident of Country Manor Health Care and Rehab Center. The information may include your name, location in the facility, and your religious affiliation. The information may be provided to visitors who ask for you by name. If you would like to decline participation in a facility directory, please request the Opt Out form from Social Services personnel.

Individuals Involved in Your Care or Payment for Your Care: We may disclose health information about you to a friend or family member who is involved in your health care or who helps pay for your care.

Organized Health Care Arrangement: Country Manor Campus has organized and is presenting to you this document as a joint notice covering all health care operations within the facility. These operations include: Country Manor Health Care and Rehab Center, Country Store and Pharmacy, and Country Manor Home Health Care. Health information will be available to employees of each operation as necessary to carry out treatment, payment, and health care operations. It is the intent of Country Manor that the amount of health information used/accessed by any of its employees be kept to the Minimum Necessary to meet your health care needs.

As required by law: We may use and disclose health information for the following types of entities, including but not limited to:

Food and Drug Administration
Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability
Correctional Institutions
Workers Compensation Agents
Health Oversight Agencies
Funeral Directors, Coroners, and Medical Directors
National Security and Intelligence

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid supbeona, or to a law enforcement officer investigating a crime.

State-Specific Requirements: Many states have requirements for reporting, including population based activities relating to improving health or reducing health care costs.

Your Health Information Rights

Although your health record is the physical property of the Country Manor Campus, you have the Right to:

Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Charges for copies will be billed following accepted state standards.

Amend: If you feel that health information 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 the facility. We may deny your request for an amendment. If this occurs, you will be notified in writing of the decision.

An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of disclosures we make of your health information

Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operation. You have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. The law does not require us to comply with your restriction requests, but we will make attempts to agree with reasonable restrictions that you request. If we do agree with your request, we will comply with it unless the information is needed to provide you with emergency treatment. If we are unable to comply with your request, you will be notified in writing.

Request Confidential Communications: You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. We are not required to agree with this request, but we will comply to the extent that it is reasonable for us to do so.

A paper copy of this notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

CHANGES TO THIS NOTICE

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have as well as any information we compile in the future. The current notice will be posted in the Facility, and include the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Country Manor by calling and asking for the Privacy Officer. You may also contact the Secretary of the Department of Health and Human Services. You will be required to submit your complaint in writing. You will not be penalized in any way for filing a complaint.

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 permission. If you provide us permission to use or disclose health information about you, you may revoke it, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

For more information about privacy issues, contact Kevin Harguth, Privacy Officer, at 320-253-1920 ext. 153, or email Kevin.Harguth@bhshealth.org.

	Notice of Privacy Practices
Health Care Center Champion Rehab Services The Country Villa & Senior Apartments Home Health Care Country Care-A-Van Country Store & Pharmacy Kids Country Child Care Job Opportunities Volunteer Opportunities Fund Development Publication - The Vine	Effective Date: 4/14/2003 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have questions about this notice, please contact the Facility Privacy Officer. This notice applies to all records of your care generated by Country Manor. Our Responsibilities Country Manor has always been committed to protecting the confidentiality of your health information. We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. If you have any questions about the content of this notice, please contact the Privacy Officer. Country Manor will not use/disclose your health information without authorization, except as described below in this notice. Uses and Disclosures How we may use and disclose Health Information about you. The following categories describe examples of the way we use and disclose health information: Treatment: We may use health information about you to provide treatment and services to you. We may disclose health information about you to doctors, nurses, technicians, or other health care facilities who are involved in taking care of your health needs. For example: we may need to exchange information about your health with other current health care providers (such as hospitals, pharmacies, nursing facilities) in order to set an appropriate course of treatment to meet your needs. We may also provide a subsequent health care provider with copies of various reports that should assist in treating your health care needs. Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or from 3rd parties. For example: we may need to provide your insurance company with information on the type of health care services and medications we are providing to you so that they will reimburse Country Manor for your treatment. Health Care Operations: Members of our staff may use information in your health records to assess the care and outcomes in your case and others like it. The results can be used to improve the quality of services provided in our Facility. For example: we may combine the health information about many residents with the same health care needs in order to evaluate the effectiveness of certain treatment procedures. We may also use and disclose health information: To business associates we have contracted with to perform the agreed upon service and billing for it; To remind you that you have a pending appointment for medical care; To assess your satisfaction with our services; To tell you about possible treatment alternatives; To contact you as a part of fund raising efforts; To inform Funeral Directors consistent with applicable law; For Population based activities relating to improving health or reducing health care costs; and For Fund Raising efforts For conducting employee training programs. Business Associates: There are some services provided in our organization through contracts with business associates. Examples include: Employee Health Care, Independent Accounting Services, and various Clinical Software Vendors. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do in order to facilitate the health care needs of our residents and employees. To protect your health information, we require the business associate to appropriately safeguard your information. Directory: We may include certain limited information about you in our facility directory while you are a resident of Country Manor Health Care and Rehab Center. The information may include your name, location in the facility, and your religious affiliation. The information may be provided to visitors who ask for you by name. If you would like to decline participation in a facility directory, please request the Opt Out form from Social Services personnel. Individuals Involved in Your Care or Payment for Your Care: We may disclose health information about you to a friend or family member who is involved in your health care or who helps pay for your care. Organized Health Care Arrangement: Country Manor Campus has organized and is presenting to you this document as a joint notice covering all health care operations within the facility. These operations include: Country Manor Health Care and Rehab Center, Country Store and Pharmacy, and Country Manor Home Health Care. Health information will be available to employees of each operation as necessary to carry out treatment, payment, and health care operations. It is the intent of Country Manor that the amount of health information used/accessed by any of its employees be kept to the Minimum Necessary to meet your health care needs. As required by law: We may use and disclose health information for the following types of entities, including but not limited to: Food and Drug Administration Public Health or Legal Authorities charged with preventing or controlling disease, injury, or disability Correctional Institutions Workers Compensation Agents Health Oversight Agencies Funeral Directors, Coroners, and Medical Directors National Security and Intelligence Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid supbeona, or to a law enforcement officer investigating a crime. State-Specific Requirements: Many states have requirements for reporting, including population based activities relating to improving health or reducing health care costs. Your Health Information Rights Although your health record is the physical property of the Country Manor Campus, you have the Right to: Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. Charges for copies will be billed following accepted state standards. Amend: If you feel that health information 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 the facility. We may deny your request for an amendment. If this occurs, you will be notified in writing of the decision. An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of disclosures we make of your health information Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operation. You have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. The law does not require us to comply with your restriction requests, but we will make attempts to agree with reasonable restrictions that you request. If we do agree with your request, we will comply with it unless the information is needed to provide you with emergency treatment. If we are unable to comply with your request, you will be notified in writing. Request Confidential Communications: You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. We are not required to agree with this request, but we will comply to the extent that it is reasonable for us to do so. A paper copy of this notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing. CHANGES TO THIS NOTICE We reserve the right to change this notice and the revised or changed notice will be effective for information we already have as well as any information we compile in the future. The current notice will be posted in the Facility, and include the effective date. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with Country Manor by calling and asking for the Privacy Officer. You may also contact the Secretary of the Department of Health and Human Services. You will be required to submit your complaint in writing. You will not be penalized in any way for filing a complaint. 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 permission. If you provide us permission to use or disclose health information about you, you may revoke it, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. For more information about privacy issues, contact Kevin Harguth, Privacy Officer, at 320-253-1920 ext. 153, or email Kevin.Harguth@bhshealth.org.

Notice of Privacy Practices