We are required to protect personal information we collect about you and your treatments by maintaining physical and procedural safeguards that meet applicable rules and regulations. Third parties that we deal with, either in the provision of services directly to you or in other non-clinical arenas must agree to follow appropriate standards of security and confidentiality.

We train the staff that works for us on how to properly handle personal information during their initial orientation and at least annually thereafter. Additionally, we have recently revised our policies on disclosure of medical information to come into compliance with current state and Federal laws and we will abide by the terms and contents of this notice.

As a resident of Lincoln Park Manor, you have several rights with regard to your health information, including the following:

• The right to request that we not use or disclose your health information in certain ways.
• The right to request to receive communications in an alternative manner or location.
• The right to access and obtain a copy of your health information.
• The right to request an amendment to your health information.
• The right to an accounting of disclosures of your health information.

We do however reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes in the Facility Information Book, maintained just outside the Beauty Shop as well as on our web site www.LincolnParkSeniors.com. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not disclose or use your health information without your authorization, except as described in this notice.

Each time you visit Lincoln Park Manor, a record of your stay is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This record, often called your Medical Record, serves as a:

• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Tool in educating health professionals
• Source of data for medical research
• Source of information for public health officials who oversee the delivery of health care in the United States
• Source of data for facility planning and marketing
• Tool with which we can assess and continually work to improve the care we render and the outcome we achieve.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information and make more informed decisions when authorizing disclosure to others.

Like most health care providers, we collect the following types of information about you:

• Information we receive directly or indirectly from you, a family member(s), your guardian, agent or someone you’ve named to speak for you relating to the provision of and/or payment for health care services.
• At times, we may receive healthcare information about you from hospitals, home health agencies, physician practices, Assisted Living facilities and other Long Term Care facilities.
• We also request and receive electronically, by telephone, in writing or in person, financial information about your health care coverage from your insurance company, or others assuming the responsibility to pay for your care at Lincoln Park Manor.

We may disclose any of the above information that we collect to affiliated and non-affiliated third parties as further described.

The affiliate to whom we may disclose personal information about you is MV Senior Management, the management company responsible for the operations of the facility; and One Lincoln Park, a residential retirement facility. The disclosures usually consist of financial data, such as monies due to the facility by you, or someone responsible for the payment of your bills.

On occasion, a member of the staff will be privy to clinical information used for quality improvement activities; or if necessary for collections of delinquent accounts. Information released to One Lincoln Park will be that information appropriate to making residential living choices.

When necessary for a resident’s care or treatment, we may disclose personal information to nonaffiliated third party health care providers (doctors, dentists, pharmacies, hospitals and other care givers), third party payors (insurance companies, financial Powers-of-Attorney, Medicare intermediaries and others who may be financially responsible for payment for services), vendors, consultants or government authorities and their respective agents.

Here are some examples of what we do with the information we collect and the reasons it might be disclosed to a third party:

• For continuity of care, we receive information from other providers that assist us in providing care at our facility. We usually receive medical histories, treatment regimens, rehabilitation records, drug administration information and other pertinent clinical data. We may disclose clinical information to other providers such as consulting practitioners, emergency rooms or after-care providers, such as Hospice, home health agencies or outpatient treatment centers.
• We will disclose your health information for payment, including payment activities of other health care providers or payers. For example, a bill we may send to your insurance carrier, or Medicare will have information that identifies you as well as your diagnosis, procedures and supplies used.
• Quality assessment and improvement activities such as the facilities Performance Improvement Program.
• Performing mandatory licensing, regulatory compliance/reporting and other health activities, responding to requests for information from regulatory authorities, responding to government agency or court subpoenas as required by law, reporting alleged or actual mistreatment, neglect, abuse or misappropriation of resident property and conducting litigation or similar dispute resolution activities.
• 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, attorneys and accrediting agencies. We may disclose you 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 do require the Business Associates to appropriately safeguard your information.

In accordance with our policy, we may disclose personal information to affiliated or non-affiliated parties as otherwise permitted by law. For other purposes, we seek special consents before disclosing the information. In the event that a special consent is needed, but the resident is unable to provide that consent, we accept consent from any person legally designated to give consent on behalf of the resident. Examples of other disclosures may include:

• A Facility Directory that has your name, location, admission date, confidential contact, fact of discharge and religious affiliation. If anyone asks for you by name we may disclose the above except for religious affiliation, which would be provided only to members of the clergy.
• It is our practice to display nursing residents’ names on a plaque on the wall outside their door and to print their name, room number, physician, sex and code status on an arm bracelet. We may take photographs of residents for use within the facility as identification and during activity events or outings. We may also print resident names and/or date of birth in the resident newsletter.
• For residents in semi-private rooms, at times, while not disclosed purposely, a roommate and/or their visitor could overhear Protected Health Information.
• We may disclose information for Notification purposes that will assist in notifying a family member, personal representative or other person responsible for your care of your location and general condition. We may be able to leave this information as a message for them on an answering machine if they have provided us with a phone number.
• We may communicate 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.
• We may disclose information to researchers when certain conditions have been met.
• We may disclose health Information at Death to funeral directors, medical examiners and coroners to carry out their duties.
• Consistent with applicable law we may disclose health information to Organ Procurement Organizations.
• 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.
• We may disclose to the Food and Drug Administration (FDA) health information relating to adverse events with respect to food, supplements, products and product defects, or surveillance information regarding product recalls, repairs or replacements.
• We may disclose health information relating to Workers Compensation claims.
• As required by law we will disclose health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
• We may disclose to a Correctional Institution, should you have inmate status, health information that will allow them to protect or treat health related conditions.
• We may disclose health information for Law Enforcement proposes as required by law or in response to a valid subpoena, warrant or court order.
• Federal law makes provision for your health information to be released to an appropriate authority provided that that authority in good faith believes that we have engaged in unlawful conduct, violated professional or clinical standards and are potentially endangering on or more residents, workers or the public.

Although your health record is the physical property of Lincoln Park Manor, the information in your health record belongs to you. You have the following rights:

• You may request that we not use or disclose your health information for a particular reason related to treatment, payment, Lincoln Park Manor’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 the facility. Although we will consider the request with regard to the use of your health information, please be aware that we are under no obligation to accept or abide by it. 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 transferred to another health care institution, or disclosure is required by law. 42 C.F.R. § 483.10(e).
• 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 alternate locations. Such request must be made in writing and submitted to the Executive Director or Privacy Officer – both may be reached by calling (937) 297-4300. We will attempt to honor all reasonable requests. 45 C.F.R. § 164.522(b).
• 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 to better respond to your request we ask that you make such requests in writing on our facility’s standard form. If you request copies, we will charge you a reasonable fee. 45 C.F.R. § 164.524.
• 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 make such requests in writing on our facility’s standard form. In the event that we do not agree to make the requested change in your record, you have the right to submit a Statement of Disagreement on a form which we will provide. 45 C.F.R. § 164.526.
• You may request that we provide a written accounting of all the disclosures made by us during the time period for which you request (not to exceed 6 years or for any date prior to April 14, 2003). We ask that you make such requests in writing on our facility’s standard form. That accounting does not include the following: disclosures made for reasons of treatment, payment or health care operations; disclosures made to you or your legal representative, or any other individual involved with your care; disclosures specifically authorized by you; disclosures made to correctional institutions or law enforcement officials and disclosures for national security purposes. You will not be charged for the first request in any 12 month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost based-fee. 45 C.F.R. § 164.528.
• You have a right to obtain a paper copy of this Notice of Privacy Practices upon request, or you may access and print a copy from our website, www.LincolnParkSeniors.com.
• 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 in writing.