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This notice describes the way medical information
about you may be used and disclosed and how you or your personal
representative (Health Care Proxy) can access your protected health
information. Please review it carefully. This notice takes effect on APRIL 14, 2003 and remains
in effect until we replace it.
OUR PLEDGE REGARDING
MEDICAL INFORMATION
The privacy of your medical information is
important to us. We understand that your medical information is
personal and we are committed to protecting it. We create a record of the care and
services you receive at Amsterdam Nursing Home. We need this record to provide you
with quality care and to comply with legal requirements. This notice will tell you about the
ways we may use and share medical information about you. We also describe your rights and
certain duties we have regarding the use and disclosure of medical
information.
OUR LEGAL DUTY
Law
Requires Us To:
-keep your medical information private
-give you notice describing our legal duties,
privacy practices, and your rights regarding medical information
-follow the terms of this notice
We Have
The Right To:
-change our privacy practices and the terms of
this notice at any time provided that the changes are permitted by
law
-make changes in our privacy practices and the new
terms of our notice effective for all medical information that we
keep, including information previously created or received before the
changes
Notice of Change to Privacy Practices:
-before we make an important change in our privacy
practices, we will change this notice and make the new notice
available upon request.
USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways
that we use and disclose medical information. Not every use or
disclosure will be listed.
However, we have listed all of the different ways we are
permitted to use and disclose medical information. We will not use
or disclose your medical information for any purpose not listed
below, without your specific written authorization. Any specific authorization you
provide may be revoked at any time by writing to us.
-FOR TREATMENT: We may use medical information
about you to provide you with medical treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, medical students, or other
healthcare providers that may be consultants (not employees of our
facility) to assist them in treating you.
-FOR PAYMENT: We
may use and disclose your medical information for payment purposes.
-FOR HEALTH CARE OPERATIONS: We may use and disclose your
medical information for our health care operations. This might include measuring and
improving quality, evaluating the performance of employees,
conducting training programs, and getting the accreditation,
certificates, licenses and credentials we need to serve you.
-ADDITIONAL USES AND DISCLOSURES: In addition to using and
disclosing your medical
information for treatment, payment, and health care operations, we
may use and disclose medical information for the following purposes:
-facility directory: unless you notify us that you
object, the following medical information about you will be placed in
our facilities’ directories:
your name, location in the facility; your condition in general
terms; your religious affiliation (if any). We may disclose this information to
members of the clergy or, except for your religious affiliation, to
others who contact us and ask for information about you by name.
-notification: medical information to notify or
help notify: a family member, your personal representative, or
another person responsible for your care. We will share information about
your location, general condition or death. If you are present, we will get
your permission if possible before we share, or give you the opportunity
to refuse permission. In case
of emergency, and if you are not able to give or refuse permission,
we will share only the health information that is directly necessary
for your health care, according to our professional judgment. We will also use our professional
judgment to make decisions in your best interest about allowing
someone to pick up medicine, medical supplies, x-ray or medical
information for you.
-disaster relief: medical information with a public
or private organization or person who can legally assist in disaster
relief efforts.
-fundraising: we may provide medical information
to one of our affiliated fundraising foundations to contact you for
fundraising purposes. We will
limit our use and sharing to information that describes you in
general, not personal terms, and the dates of your health care. In any fundraising materials, we
will provide you a description of how you may choose not to receive
future fundraising communications.
-Research in limited circumstances: medical information for research purposes
in limited circumstances where the research has been approved by a
review board that has reviewed the research proposal and established
protocols to ensure the privacy of medical information.
Amsterdam
Nursing Home Privacy Practice
Notice (p.2)
-funeral director, coroner, medical examiner: to help them carry out their
duties, we may share the medical information of a person who has died
with a coroner, medical examiner, funeral director, or an organ
procurement organization.
-specialized government functions: subject
to certain requirements, we may disclose or use health information
for military personnel and veterans, national security, and
intelligence activities, for protective services for the President
and others, for medical suitability determinations for the Dept of
State, for correctional institutions and other law enforcement
custodial situations, and for government programs providing public
benefits.
- court orders
and judicial and administrative proceedings: we may disclose medical information
in response to a court or administrative order, subpoena, discovery
request, or other lawful purpose under certain circumstances. Under limited circumstances, such
as court order, warrant, or grand jury subpoena, we may share your
medical information with law enforcement officials. We may share limited information
with a law enforcement official concerning the medical information of
a suspect, fugitive, material witness, crime victim, or missing
person. We may share the
medical information of an inmate or other person in lawful custody
with a law enforcement official or correctional institution under
certain circumstances.
-public health activities: as required by
law, we may disclose your medical information to public health or
legal authorities charged with preventing or controlling disease,
injury, disability, or
neglect. We may also disclose
your medical information to persons subject to jurisdiction of the Food
and Drug Administration for purposes of reporting adverse events
associated with product defects or problems, to enable product
recalls, repairs, or replacements, to track products, or to conduct
activities required by the Food and Drug Administration. We may also,
when we are authorized by law to do so, notify a person who may have
been exposed to a communicable disease or otherwise be at risk of
contracting or spreading a disease or condition.
-victims of abuse, neglect, or domestic
violence: we may disclose
medical information to appropriate authorities if we reasonably believe
that your are a possible victim of abuse,
neglect, or domestic violence or the possible victim of their
crimes. We may share your
medical information when necessary to help law enforcement officials
capture a person who has admitted to being part of a crime or has
escaped from legal custody.
-workers compensation: we may disclose health information
when authorized and necessary to comply with laws relating to workers
compensation or other similar programs.
-health oversight activities: we may disclose medical information
to an agency providing oversight for oversight activities authorized
by law, including suits, civil, administrative or criminal
investigations or proceedings, inspections, licensure or disciplinary
actions, or other authorized activities.
-law enforcement: under certain circumstances, we may
disclose health information to law enforcement officials. These circumstances include
reporting required by certain laws (such as the reporting of certain
types of wounds), pursuant to certain subpoenas or court orders,
reporting limited information concerning identification and location
at the request of a law enforcement official, reports regarding
suspected victims of crimes at the request of a law enforcement
official, reporting death, crimes on our premises, and crimes in
emergencies.
YOUR INDIVIDUAL RIGHTS : You Have A Right To:
- Look at or get copies
of your medical information. You may request that we provide
copies in a format other than photocopies. We will use the format you
request unless it is not practical for us to do so. You must make your request in
writing. You may get the
form to request access from your Social Worker or the Privacy
Officer in the Medical Record Department. You may also request access by
sending a letter to the Privacy Officer. Copies are .75 cents per page
and will be mailed to you.
- Receive
a list of all times we or our business associates shared your
medical information for purposes other than treatment, payment
and health care operations and other specified exceptions.
- Request
that we place additional restrictions on our use or disclosure
of your medical information.
We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement
(except in case of an emergency).
- Request
that we communicate with you about your medical information by
different means or to different locations. Your request that we
communicate your medical information to you by different means
or at different locations must be made in writing to the Privacy
Officer (listed at the end of this notice).
- Request
that we change your medical information. We may deny your
request if we did not create the information you want changed or
for certain other reasons.
If we deny your request, we will provide you a written
explanation. You may
respond with a statement of disagreement that will be added to
the information you wanted changed. If we accept your request to
change the information, we will make reasonable efforts to tell
others, including people you name, of the change and to include
the changes in any future sharing of that information.
QUESTIONS AND COMPLAINTS: If you have any questions about
this notice or if you think that we may have violated your privacy rights,
please contact the Amsterdam Nursing Home Privacy Officer at
212-316-7769 or write to:
Privacy Officer/Director of Medical Records
Amsterdam
Nursing Home
1060 Amsterdam Ave.
N.Y., N.Y. 10025
You may also submit a written complaint to the
U.S. Dept of Health and Human Services.
We will not retaliate in any way if you choose to
file a complaint.
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