Notice of Privacy Practices

|   Information on privacy of your health information

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.

Providence Life Services is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. The organization will not use or disclose your health information except as described in this notice. This notice applies to all of the medical records generated or received by Providence Life Services.

The privacy practices summarized in this notice will be followed by:

• Our employees, volunteers, and trainees in our operations.
• Members of our organized health care arrangement or affiliated covered entities
  with which we share information.
• Any business associate with which we share health information.
  

TREATMENT
In order to adequately treat our residents and patients, we provide complete information to healthcare providers, including members of our workforce and business associates. For example, a nurse caring for you will report any changes in your condition to a physician, a therapist, other nurses, and/or nurse's aides so that you can receive the treatment you need.

PAYMENT
Health information is exchanged daily with various payers: Medicare, Medicaid, private insurances, third party payers, or other entities (or their authorized representatives) involved in the payment of your medical bill. This information is used to verify benefits, submit for payment, and project and arrange for future care. For example, a bill sent to an insurance company may include information that identifies you, your diagnosis, and any procedures or supplies used.

HEALTHCARE OPERATIONS
The organization may use or disclose your health information as a part of healthcare operations. Examples of daily operations in which such information may be used include: quality assurance, internal auditing, certification, licensure, and educational purposes.

APPOINTMENT REMINDERS
Providence Life Services may use and disclose health information to contact you as a reminder that you are scheduled for further treatment or medical care.

DIRECTORY
Unless you object, Providence may include certain limited contact information (your name and location) in a directory while you are a resident at one of our campuses, so that your family and friends can easily visit you. We may also use your name on your door to assist in identifying your room.

BUSINESS ASSOCIATES
Providence may use and disclose certain health information about you to business associates. A business associate is an individual or entity that works with the organization to perform or assist the organization in a function or activity, which necessitates the use or disclosure of health information. Examples of business associates include, but are not limited to, the medical director, consultants, lawyers, and third party billing companies. We require all our business associates to protect the confidentiality of your health information.

FUNDRAISING
Providence may use your demographic information to contact you in an effort to raise funds for the organization. Additionally, the organization may disclose the same demographic information to a foundation related to the organization, who may contact you in fundraising efforts for the organization. If you choose not to participate in this please notify the administrator in writing of your desires.

REGULATORY AGENCIES
Providence Life Services may disclose your health information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations, and inspections. These activities are necessary for the government and certain private health oversight agencies to monitor the healthcare system, government programs, and compliance with civil rights.

LAW ENFORCEMENT/LITIGATION
The organization may disclose your health information for law enforcement purposes as required by law or in response to a valid subpoena, court order, or other lawful purpose.

DISASTER RELIEF
We may disclose your personal health information to an organization assisting in a disaster relief effort.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
Providence may disclose health information to authorized federal officials conducting national security and intelligence.

PUBLIC HEALTH
As required by law, Providence may disclose your health information to public health authorities charged with preventing or controlling disease, injury, or disability.

WORKERS COMPENSATION
We may release health information about you to Workers Compensation, which provides benefits for work-related injuries or illnesses.

FUNERAL DIRECTORS, CORONERS, MEDICAL EXAMINERS, ORGAN PROCUREMENT ORGANIZATIONS
Providence Life Services may release your health information to a funeral director if needed to carry out funeral-related duties.

REPORTING VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
If we believe that you have been a victim of abuse, neglect, or domestic violence, we may disclose your personal health information to notify a government authority if required or authorized by law.

OTHER USES
Uses and disclosures of an individual's health information for purposes other than those listed will be made only with the resident's or patient's written authorization, which later may be revoked.

INDIVIDUAL RIGHTS
The resident or patient has the following rights related to his or her health information:

1. The right to request restrictions on our use or disclosure of your personal health information. You also have the right to restrict the personal health information we disclose about you to a family member, friend, or other person who is involved in your care or in payment for your care. We are required to agree to your requested restriction unless (1) you are being transferred to another health care institution, (2) the release of records is required by law, or (3) the release of information is needed to provide you emergency treatment.
2. The right to receive confidential communication of personal health information by alternate means or at an alternate location (for example, your home).
   
3. The right to inspect and have copied personal health information.
4. The right to amend personal health information
   a. Your request must be in writing.
   b. There are limitations to amendatory rights.
5. The right to receive an accounting of disclosures of protected health information.
   a. Your request must be in writing.
   b. Charges may apply.
   
6. The right to receive a copy of this notice upon request or access it at www.providencelifeservices.com.
   
7. The right to revoke your authorization to use or disclose your health information, except to the extent that action has already been taken with your authorization.

REPORTING OF CONCERNS OR NEED FOR MORE INFORMATION
If you have questions or would like additional information you may contact the Administrator or the Privacy Officer at Providence Life Services (708-342-8137). If you believe your privacy rights have been violated, you may file a complaint with the organization or the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. There will be no retaliation for submitting a complaint.

CHANGES TO THIS NOTICE
Providence Life Services will abide by the terms of the notice currently in effect. The organization reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information it maintains. If the organization changes this notice, a copy of the revised notice will be mailed to the resident or patient.