1) Effective Date of This Notice: April 14, 2003

2) Who Will Follow This Notice: This notice describes the practices of our nursing facility and of the
following persons and entities:
a) Any health care professional authorized to enter information into your medical chart.
b) All departments and units of this facility.
c) Any volunteer and contractor who provides services to you while you are in our facility.
d) All employees, staff and other facility personnel.
e) The following classes of providers and suppliers and their employees: laboratories; physical,
occupational, speech and respiratory therapy providers; transportation providers; radiology
providers; pharmacies; audiology providers; dietary providers; and medical supply companies.
f) The following classes of individual health care providers: attending physicians; optometrists;
ophthalmologists; dentists; podiatrists; psychologists; and psychiatrists.
All of the persons and entities noted above will follow the terms of this notice with regard to your
health information for services provided in our nursing facility or to you while you are a resident in
our facility regardless of where the services are actually provided. In addition, these persons and
entities may share your health information with each other for treatment, payment or other health
care operations purposes as described in this notice.

3) How We Will Use or Disclose Your Health Information
a) Treatment. We will use or disclose your health information for treatment purposes, including for
the treatment activities of other health care providers. For example, information obtained by a
nurse, physician, or other member of your healthcare team will be recorded in your record and
used to determine the course of treatment that should work best for you. Your physician will
document in your record his or her expectations of the members of your healthcare team.
Members of your healthcare team will then record the actions they took and their observations.
In that way, the physician will know how you are responding to treatment. We will also provide
your physician or a subsequent healthcare provider with copies of various reports that should
assist him or her in treating you once you’re discharged from our nursing facility.
b) Payment. We will use or disclose your health information for payment, including for the payment
activities of other health care providers or payers. For example, a bill may be sent to you or a
third-party payer, including Medicare or Medicaid. The information on or accompanying the bill
may include information that identifies you, as well as your diagnosis, procedures, and supplies

c) Health care operations. We will use or disclose your health information for our regular health
operations. For example, members of the medical staff, the risk or quality improvement manager,
or members of the quality improvement team may use information in your health record to assess
the care and outcomes in your case and others like it. This information will then be used in an
effort to continually improve the quality and effectiveness of the health care and service we
In addition, we will disclose your health information for certain health care operations of other
entities. However, we will only disclose your information under the following conditions: (a) the
other entity must have, or have had in the past, a relationship with you; (b) the health information
used or disclosed must relate to that other entity’s relationship with you; and (c) the disclosure
must only be for one of the following purposes: (i) quality assessment and improvement activities;
(ii) population-based activities relating to improving health or reducing health care costs; (iii) case
management and care coordination; (iv) conducting training programs; (v) accreditation,
licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.
d) Business associates. There are some services provided in our organization through the use of
outside people and entities. Examples of these “business associates” include our accountants,
consultants and attorneys. We may disclose your health information to our business associates
so that they can perform the job we’ve asked them to do. To protect your health information,
however, we require the business associates to appropriately safeguard your information, and
they are also required to do so by law.
e) Directory. Unless you notify us that you object, we may use your name, location in the facility,
general condition, and religious affiliation for directory purposes. This information may be
provided to members of the clergy and, except for religious affiliation, to other people who ask
for you by name. We may also use your name on a nameplate next to or on your door in order to
identify your room, unless you notify us that you object.
f) Notification. We may use or disclose information to notify or assist in notifying a family member,
personal representative, or another person responsible for your care, of your location, and
general condition. If we are unable to reach your family member or personal representative, then
we may leave a message for them at the phone number that they have provided us, e.g., on an
answering machine.
g) Communication with family. We may disclose to a family member, other relative, close personal
friend or any other person involved in your health care, health information relevant to that
person’s involvement in your care or payment related to your care.
h) Marketing. We may contact you regarding your treatment, to coordinate your care, or to direct
or recommend alternative treatments, therapies, health care providers or settings. In addition,
we may contact you to describe a health-related product or service that may be of interest to you,
and the payment for such product or service.
i) Fundraising. We may contact you as part of a fund-raising effort.

j) Other uses & disclosures. We may use or disclose your protected health information in the
following situations without your authorization since these uses and disclosures are required or
permitted by law without such authorization:
▪ As required by law
▪ For public health activities, such as reporting to the Federal Drug Administration or the
Occupational Safety and Health Administration
▪ About victims of abuse, neglect or domestic violence
▪ For health oversight activities
▪ For judicial and administrative proceedings
▪ For law enforcement purposes
▪ About decedents, such as releases to coroners, medical examiners and funeral directors
▪ For cadaveric organ, eye or tissue donation purposes
▪ For research certain purposes where we have permission from an institutional review board
or privacy board
▪ To avert a serious threat to health or safety
▪ For specialized government functions, such as national security
▪ For workers’ compensation

4) Your Health Information Rights
Although your health record is the physical property of the nursing facility, the information in your
health record belongs to you. You have the following rights:
a) You may request that we not use or disclose your health information for a particular reason
related to treatment, payment, the Facility’s general health care operations, and/or to a particular
family member, other relative or close personal friend. We ask that such requests be made in
writing on a form provided by our facility. Although we will consider your requests with regard to
the use of your health information, please be aware that we are under no obligation to accept it
or to abide by it, unless it is a request to prohibit disclosures to your health care plan relating to a
service for which you have already paid in full out of pocket. We will abide by your requests with
regard to the disclosure of your clinical and personal records to anyone outside of the facility,
except in an emergency, if you are being transferred to another health care institution, or the
disclosure is required by law
b) If you are dissatisfied with the manner in which or the location where you are receiving
communications from us that are related to your health information, you may request that we
provide you with such information by alternative means or at alternative locations. Such a request
must be made in writing, and submitted to the administrator. We will attempt to accommodate
all reasonable requests.
c) You may request to inspect and/or obtain copies of health information about you, which will be
provided to you in the time frames established by law. You may make such requests orally or in
writing; however, in order to better respond to your request, we ask that you make such requests
in writing on our facility’s standard form. If you request to have copies made, we will charge you

the community standard rate established by state law for copies of medical records requested
from health care providers, such as hospitals and doctors.

d) If you believe that any health information in your record is incorrect or if you believe that
important information is missing, you may request that we correct the existing information or add
the missing information. Such requests must be made in writing, and must provide a reason to
support the amendment. We ask that you use the form provided by our facility to make such
requests. For a request form, please contact the Privacy Officer.
e) You may request that we provide you with a written accounting of all disclosures made by us
during the time period for which you request (not to exceed 6 years). We ask that such requests
be made in writing on a form provided by our facility. Please note that an accounting will not apply
to any of the following types of disclosures: disclosures made for reasons of treatment, payment
or health care operations; disclosures made to you or your Representative, or any other individual
involved with your care; disclosures made pursuant to a valid authorization; disclosures to
correctional institutions or law enforcement officials; and disclosures for national security
purposes. You will not be charged for your first accounting request in any 12-month period.
However, for any requests that you make thereafter, you will be charged a reasonable, cost-based
f) You have the right to obtain a paper copy of our Notice of Privacy Practices upon request. You
may also access and print a copy of our notice from our website:
g) You may revoke an authorization to use or disclose health information, except to the extent that
action has already been taken. Such a request must be made in writing.

5) For More Information or to Report a Problem
If you have questions and would like additional information, you may contact our facility’s
Administrator at 330-875-5562.
If you believe that your privacy rights have been violated, you may file a complaint with us. These
complaints must be filed in writing on a form provided by our facility. The complaint form may be
obtained from social services, and when completed should be returned to the administrator. You may
also file a complaint with the secretary of the federal Department of Health and Human Services.
There will be no retaliation for filing a complaint.

Download A Copy Of Our Privacy Policy Here