THIS POLICY DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1.1. Any healthcare professional authorized to enter information into your medical record chart
1.2. Any member of a volunteer group we allow to help while you are in the Facility
1.3. Any employees, staff and other the Facility personnel.
In addition, the Facility may share information with other health care providers for treatment, payment or health care operations purposes described in this policy.
2. Our Pledge Regarding Medical Information: We understand that protected health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at the Facility. We need this record to provide you with quality care and to comply with certain legal requirements. This policy applies to all of the records of your care or about your care generated by the Facility and your personal physician. Your physician may have different policies or policies regarding the physician’s use and disclosure of your medical information created in the physician’s office or
This policy will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information.
We are required by law to:
• Make sure that protected health information that identifies you is kept private (with certain exceptions)
• Give you this policy of our legal duties and privacy practices with respect to protected health information about you, and
• Follow the terms of this policy that are currently in effect.
3. How We May Use and Disclose Your Health Information: The following categories describe different ways that we use and disclose protected health information. For each category of uses or disclosures, we will explain what we mean and 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.
3.1. We May Disclose Information for Your Care and Treatment: We may use or disclose your protected health information to provide you with medical treatment, care and services. For example, we may disclose your protected health information to health care providers who are involved in your care to assist them in your diagnosis and treatment as necessary. For example, if you leave the Facility and will be transferred to another hospital or to assisted living we will disclose your protected health information to individuals who will be involved in your care for the purpose of continuity of care.
3.2. We May Disclose Information for Payment: We will use and disclose your protected health information so that treatment and services you receive at the Facility may be billed to and payment may be collected from you, an insurance company or a third party. The information on an accompanying bill will include information that identifies you as well as your diagnosis, procedures and supplies used.
We may also disclose your protected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and how it is owed. We will have a contract with the health care provider that obligates that provider to maintain the confidentiality of your protected health information. As an example, if you use supplies for the treatment of diabetes, we will give information to another provider so that they may bill for reimbursement of the cost.
3.3. We May Disclose Information for Health Care Evaluation: We will use and disclose protected health information about you for health operations. These uses and disclosures are necessary to manage the Facility and to make sure that all of our residents receive quality care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff caring
for you. We may also disclose information to doctors, nurses, technicians and other personnel for review
and learning purposes.
3.4. We May Disclose Information for Appointment Reminders: We may use or disclose your protected health information to remind you about appointments.
3.5. We May Disclose Information for Treatment Alternatives or Health-Related Benefits or Services: We may use or disclose your protected health information to inform you about treatment alternatives or health related benefits and services that may be of interest of you.
3.6. We May Disclose Information for the Facility Directory: Your name, location and general condition (e.g. fair, stable, etc.) may be put into our facility directory. The information will be released to people who ask for you by name. This information is released so your family and friends can visit you in the hospital and generally know how you are doing.
Your religious affiliation maybe given to a chaplain even if they do not ask for you by name.
3.7. We May Disclose Information to Individuals Involved in Your Care or in Payment for Your Care: We may release protected health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. Unless there is specific written request form you, we may also tell your family or friends your condition and that you are in the Facility. In addition, we may also disclose your protected 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.
3.8. We May Disclose Information for Research: Under certain circumstances, we may use and disclose your protected health information for research purposes. For example, a research project may involve comparing the health and recovery of all Residents who received one medication to those who received another for the same condition. All research projects are subject to a special approval process through an outside Institutional Review Board. We will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are or will be involved in your care at the Facility.
3.9. We May Disclose Information as Required by Law: We will disclose protected medical information about a Resident when required to do so by federal, state or local law.
3.10.We May Disclose Information to Avert a Serious Threat to Health or Safety: We may disclose protected medical 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 would only be to someone able to help prevent the threat.
Special Situations Regarding Disclosure:
3.11.Organ and Tissue Donation: We may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank as necessary to facilitate organ and tissue donation and transplantation.
3.12.Veterans: The Facility may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.
3.13.Workers’ Compensation: We may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness.
3.14. Public Health Risks: We may disclose protected health information about you for public health activities.
These activities generally include the following:
3.14.1. To prevent or control disease, injury and disability.
3.14.2. To report deaths.
3.14.3. To report the abuse or neglect of elders and dependent adults.
3.14.4. To report reactions to medications or problems with products.
3.14.5. To notify people of recalls of products they may be using.
3.14.6. 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.
3.14.7. To notify the appropriate government authority if we believe a Resident has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
3.15.Health Oversight Activities: We may disclose your protected health information to a governmental health oversight agency for activities authorized by law. These overnight activities include audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
3.16. Lawsuits and Legal Disputes: If you are involved in a lawsuit or dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected 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 reasonable efforts have been made to tell
you about the request (which may include a written policy to you) or to obtain an order protecting the information requested.
3.17. Law Enforcement: We may release protected health information if asked to do so by a law enforcement official:
3.17.1. In response to a court order, subpoena, warrant, summons or similar process,
3.17.2. To identify or locate a suspect, fugitive, material witness, or missing person,
3.17.3. About the victim of a crime if, under certain limited circumstances, we are unable to obtain the
3.17.4. About the death we believe may be the result of criminal conduct,
3.17.5. About criminal conduct at the Facility, or
3.17.6. In emergency circumstance to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
3.18. Coroners, Medical Examiners and Funeral Directors: We may release protected medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release protected health information about Residents of the Facility to funeral directors to carry out their duties.
3.19. National Security and Intelligence Activities: We may release protected health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
3.20. Protective Services for the President and Others: We may disclose protected health information about you to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
4. Your Rights Regarding Your Protected Health Information: You have the following rights regarding your protected health information that we maintain about you:
4.1. Inspection: You have the right to inspect and copy health information that may be used to make decisions about your care.
4.1.1. Usually, this includes medical and billings records, but may not include some mental health information.
4.1.2. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Administrator at the Facility or General Counsel of Eduro Healthcare, LLC, 1376 E, 3300 S, Salt Lake City, UT 84106. If you request a copy of the information, we may charge a fee or costs of copying, mailing, printing or other expenses associated with your
4.1.3. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another independent licensed health care professional chosen by the Facility will review your request and the denial. We will comply with the outcome of the review.
4.2. Changes to Protected Health Information: If you feel that the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information.
4.2.1. Requesting Amendments: You have the right to request an amendment for as long as the information is kept by the Facility. To request an amendment, your request must be made in writing and submitted to the Administrator at the Facility or General Counsel of Eduro Healthcare, LLC, 1376 E, 3300 S, Salt Lake City, UT 84106. In addition, you must provide a reason that supports your
4.2.2. Approval of Amendments: 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 no longer available to make the amendment, 2) is not part of the medical
information kept by or for the Facility, 3) is not part of the information which you would be permitted to inspect and copy; or 4) is accurate and complete.
4.2.3. Addendums to Medical Records: Even if we deny your request for an amendment, you have the right to submit a written addendum not to exceed 250 words with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing, you want the addendum to be made part of your medical record we will attach it to your records and indicate it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
4.3. What Disclosures are Made: You have the right to know about disclosures we make to others.
4.3.1. You have the right to receive an accounting of disclosures of your protected health information. This is a list of the disclosures we made of protected health information about you other than our own uses for treatment, payment, and health care operations and with other expectations pursuant to the law. To request this list of accounting of disclosure, you must submit your request in writing
to the Administrator at the Facility or General Counsel of Eduro Healthcare, LLC, 1376 E, 3300 S, Salt Lake City, UT 84106. Your request must state a time period, which may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper, electronically).
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 lists. 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.
4.4. Restrictions on Disclosures: You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.
4.4.1. To request restrictions, you must make your request in writing to the Administrator at the Facility at or General Counsel of Eduro Healthcare, LLC at (385) 240-6408. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply, for example disclosures to your spouse.
4.4.2. We maintain complete discretion as to whether to accept or reject the requested restriction. We will furnish the Resident with a written response to the request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
4.5. Alternative Means of Communication: You have the right to request that we communicate with you about protected health information by alternative means or at alternative locations. For example, you can ask that we only contact you at work or by mail.
4.5.1. To request confidential communications, you must make your request in writing to the Administrator at the Facility or General Counsel of Eduro Healthcare, LLC at (385) 240-6408. We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
4.6. Paper Copy of Policy: You have the right to request and receive a paper copy of this policy. You may ask us to give you a copy of this policy at any time. To obtain a paper copy of this policy, please contact the business office of the Facility. You may also obtain a copy of the policy by downloading the policy from our website.
5. Changes to This Policy: We reserve the right to change this policy. We reserve the right to make the revised or changed policy effective for protected 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 policy in the Facility. In the lower right hand corner of the last page of the policy is the effective date. In addition, each time you are admitted to the Facility, we will offer you a copy of the current policy in effect.
6. To Make a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the state agency for responsible for of HIPAA and privacy compliance or the Department of Health and Human Services, Office of Civil Rights at https://www.hhs.gov/ocr/complaints/index.html. To file a complaint with the Facility, contact the Administrator at the Facility or General Counsel of Eduro Healthcare at 1376 E 3300 S, Salt Lake City, UT 84106. The telephone number is (385) 240-6408. Please note that although you may call the Privacy Officer, all official complaints must be submitted in writing. You will not be penalized for filing a complaint.
7. Written Permission Needed for Other Disclosures: Other uses and disclosures of protected health information not covered by the policy or laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected health information, you may revoke that permission, in writing at any time. If you revoke your permission, this will stop any further use or disclosure of protected health information for the purposes covered by your written authorization, unless we have already acted in reliance on your permission. 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 Additional Questions: If you have questions about this Notice of Privacy Practices and would like further information about your privacy rights, contact the Administrator at the Facility, or General Counsel of Eduro Healthcare at 1376 E 3300 S, Salt Lake City, UT 84106. The telephone number is (385) 240-6408.