NOTICE OF PRIVACY PRACTICES

Effective Date April 14, 2003
Revised June 14, 2003 

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.

This Notice is provided to you pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). It is designed to tell you how we may, under federal law, use or disclose your health information. 

PLEASE NOTE: Under the New Jersey Long Term Care Regulations, we are required to obtain your “approval” prior to releasing your information to anyone outside the nursing home, except, we are not required to obtain your approval if you transfer to another health care facility, or unless the release is required by law, a third-party payment contract, or the New Jersey State Department of Health and Senior Services. 

We will ask you to sign an Acknowledgment of the Notice. The Acknowledgment will state that you are giving your “approval” to allow us to use and disclose your Health Information as set forth in this Notice. If you wish to restrict our use or disclosure of your Health Information, you have the right to withhold your approval for all uses and disclosures other than as set forth above. You may request this restriction at any time, for any Health Information. The process for requesting such a restriction is set forth in this Notice. 

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care facility, and those that we may receive from other health care providers or facilities. The records are the property of Crest Haven Nursing and Rehabilitation Center, but the information belongs to you. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose health information. 

For each category of uses and disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. This notice describes our information privacy practices and that of:

· Any health care professional authorized to enter information into your medical record created and/or maintained at our facility.

· Any member of a volunteer group, which we allow to assist you while receiving services at Crest Haven Nursing and Rehabilitation Center.

· All employees, staff, and personnel of our organization.

All of the individuals or entities identified above will follow the terms of this notice. These individuals or entities may share your protected health information with each other for purposes of treatment, payment, or health care operations, as further described in the notice. 

FOR TREATMENT. We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, therapists, or other personnel who are involved in taking care of you. They may work at our facility, at the hospital if you are hospitalized, or at your doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a physical therapist treating you for a broken hip may need to know if you have diabetes because diabetes may slow the healing process and increase rehabilitation time. Disclosures may be made to people outside of our organization who may be involved in your health care, such as family members, hospices, or home health agencies for continued care. We may also disclose health 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.

FOR PAYMENT. We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company or third party. For example, we may need to give Medicare or Medicaid information about your stay so they will pay us or reimburse your stay. We may also tell your health plan provider 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 health information about you for operations of our health care facility. These uses and disclosures are necessary to run our facility and make sure that all of our residents receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many residents to decide what additional services we should offer, what services are needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific residents are. For example, we may access or send your information to our attorneys or accountants in the event we need the information in order to address one of our business functions. Students or personnel may view information for review or learning purposes.  

USES AND DISCLOSURES MADE PURSUANT TO YOUR VERBAL AGREEMENT.

FACILITY DIRECTORY. Unless you tell us that you object, we may use or disclose certain information about you in our directory. This information may include your name, assigned room number, religious affiliation, and a phone number. Your religious affiliation may be given to a member of the clergy. Phone numbers and room numbers may be given to individuals who may ask for you by name. Photographs may be taken and posted to alert staff of your birthday, special celebrations, or of group activities.

NOTIFICATION AND COMMUNICATION WITH FAMILY. Unless you tell us that you object, we may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, general condition or in the event of your death. If you are able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others. 

USES AND DISCLOSURES PERMITTED OR REQUIRED BY LAW 

PROVIDING INFORMATION TO YOU. Unless restricted by your attending physician who feels information would be detrimental to your health.

ORGAN AND TISSUE DONATION. If you are an organ donor, we may use or disclose your Health Information for purposes of communicating to organizations involved in procuring, banking or transplanting organs and tissues.

RESEARCH. We may disclose your health information to researchers conducting research that has been approved by the facility. Because all research projects are subject to a special approval process, we will not disclose health information unless we: (1) receive your authorization; or (2) de-identify your health information.

REQUIRED BY LAW. We will disclose health information about you when required to do so by federal, state, or local law. 

PUBLIC SAFETY. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

MILITARY AND VETERANS. If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable and in accordance with specific rules and regulations as set forth in HIPAA.

WORKERS’ COMPENSATION. We may release health information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illness. 

PUBLIC HEALTH PURPOSES. We may disclose health information about you for public health activities. These activities generally include the following:

· To prevent or control disease, injury or disability

· To report deaths

· To report reactions to medications or problems with products

· To notify people of recalls of products they may be using

· To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

· To notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect, or domestic violence. 

HEALTH OVERSIGHT ACTIVITIES. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include: audits, investigations, inspections, certifications and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

JUDICIAL AND ADMINISTRATIVE PROCEEDINGS. We may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

LAW ENFORCEMENT. We may use or disclose your Health Information to a law enforcement official to identify or locate a suspect, fugitive, material witness or missing person, comply with a court order or grand jury subpoena and other law enforcement purposes.

CORONERS, HEALTH EXAMINERS AND FUNERAL DIRECTORS. We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about residents to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS. We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons of foreign heads of state or conduct special investigations.

INMATES. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety of the health and safety of others; or (3) for the safety and security of the correctional institution.

YOU SHOULD BE ADVISED THAT WE MAY ALSO USE OR DISCLOSE YOUR HEALTH INFORMATION FOR THE FOLLOWING PURPOSES. 

FUND-RAISING. We may contact you to participate in fund-raising activities for this facility.

CHANGE OF OWNERSHIP. In the event that this facility is sold or merged with another organization, your health information/record will become the property of the new owner.

TO SCHEDULE APPOINTMENTS. We may use your Health Information in order to contact you or your personal representative about care plan or discharge planning meetings or to give you information about other treatments or health-related benefits and services that may be of interest to you.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION. All other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you give us authorization to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your authorization, 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.

STATE LAW IMPACT. To the extent that state law is more restrictive with respect to our ability to use or disclose your Health Information, or to the extent that it affords your greater rights with respect to the control of your Health Information, we will follow state law. As noted on the first page, we are obligated to obtain your “approval” in order to disclose your Health Information to persons outside of the facility, except, in cases where you transfer to another health care facility or unless the release of the information is required by law, a third-party payment contract, or the New Jersey Department of Health and Senior Services. By signing our form of Acknowledgment, you will be “approving” of our use and disclosure of your Health Information as set forth herein.

Different rules will apply if the Health Information in question contains information relating to HIV/AIDS, mental health, alcohol and/or substance abuse, genetic testing, among others. In those special cases, the handling of your Health Information will be subject to more restrictive state and/or federal rules. 

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION.

You have the following rights regarding the health information we maintain about you.

RIGHT TO INSPECT AND COPY. You have the right to inspect and copy your health information. Usually, this includes health and billing records, but does not include psychotherapy notes. To inspect and copy health information that may be used to make decisions about you, you may submit your request orally or in writing to the Privacy Officer / Health Information Director. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. Fees will be based on the community standard. To comply with OBRA regulations we will respond to your request within 24 hours (excluding weekend and holidays) and copies will be provided within two working days. 

We may deny your request to inspect and copy your protected health information in certain limited circumstances. If you are denied access to your protected health information, you may request that the denial be reviewed. Another licensed health care professional selected by our facility (Director of Nursing) 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 second review.

RIGHT TO 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 we keep the information. To request an amendment, your request must be made in writing and submitted to the Privacy Officer/Health Information Director. In addition, you must provide documentation that supports your request for an amendment.

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:

· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment

· Is not part of the health information kept by or for our facility

· Is not part of the information which you would be permitted to inspect and copy

· Is accurate and complete.

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request an accounting of any disclosures of your health information we have made, except for uses and disclosures made for treatment, payment, and health care operations, as previously described.

To request the list of disclosures, you must submit your request in writing to the Privacy Officer/Health Information Director. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request

within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before costs are incurred. We will mail you a list of disclosures in paper form within 60 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 90 days from the date you made the request.

RIGHT TO REQUEST RESTRICTION. 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 operations. You also 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 of your care, such as a family member or friend. For example, you could ask that we restrict a specific nurse from use of your information, or that we not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you.

If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to the Privacy Officer/Health Information Director. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specific nurse, or disclosure of specified condition to your spouse.

I understand that under New Jersey law, I have the right to withhold my approval for all disclosures other than set forth above and may exercise that right by requesting restrictions on all other uses and disclosures at any time, for any Health Information.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you or your health care representative about matters 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 a post office box.

To request confidential communications, you must make your request in writing to the Privacy Officer/Health Information Director. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

RIGHT TO A PAPER COPY OF THIS NOTICE. You have the right to obtain a paper copy of this notice at any time. If you would like a more detailed explanation of these rights, or if you would like to exercise one or more of these rights contact the Privacy Officer using the information provided below. You may also obtain a copy of the notice at our website, Crest Haven Nursing and Rehabilitation Center.

OUR DUTIES

We are required by law to maintain the privacy of your Health Information and to provide you with a copy of this notice.

We are also required to abide by the terms of this notice.

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, the effective date, and the dates of any revisions. We will provide you with another copy , of this notice at any time, upon request.

SUMMARY OF USES OF DISCLOSURES OF YOUR HEALTH INFORMATION:

We may use or disclose your protected health information in one of the following ways:

1. For the purposes of treatment, payment or health care operations

2. Pursuant to your verbal agreement (for use in our facility directory or to discuss your health condition with family or friends who are involved in your care).

3. As permitted or required by law

4. Pursuant to your written authorization (for purposes other than treatment, payment or health care operations) 

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the Privacy Officer/ Health Information Director.

We promise you will not be penalized for filing a complaint. 

To file a complaint at our facility or if you have any questions please contact:

CHN&RC, Privacy Officer
4 Moore Road Department 619
Cape May Court House, NJ 08210-1601
(609) 465-6807

If you are not satisfied with the manner in which this facility handles a complaint, you may submit a formal complaint t

Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

You may also address your complaint to one of the regional Offices of Civil Rights. A list of these offices can be found online at:

  http://www.hhs.gov/ocr/regmail.html