Notice of Privacy Practices

Effective Date: January 1, 2007

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.

If you have any questions about this notice, please contact Lakeland Health Care Center's Administrator at 973-839-6000.

WHO WILL FOLLOW THIS NOTICE

This notice describes Lakeland Health Care Center's practices and that of:

• Any health care professional authorized to enter information into your health record.
• All employees, staff and other personnel of Lakeland Health Care Center.
• Any member of a volunteer group we allow to help you while you are in Lakeland Health Care Center.
• All divisions, departments and units of Lakeland Health Care Center.
• All entities, sites and other facilities that are affiliated with Lakeland Health Care Center, which shall be referred to collectively as "Lakeland Health Care Center" for the purpose of this notice. These affiliated entities, sites and facilities follow the terms of this notice and may share health information with each other for treatment, payment or regular health operations purposes described in this notice.

OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that 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 Lakeland Health Care Center. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Lakeland Health Care Center, whether made by your personal doctor or other personnel. Your personal doctor may have different policies or notices regarding the doctor's use and disclosure of your health information created in the doctor's office or other location.

This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

• make sure that health information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to health information about you; and
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to 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.

For Treatment
We may use health information about you to provide you with health treatment or services. We may disclose health information about you to doctors, nurses, technicians or other personnel, students and volunteers who are involved in taking care of you at Lakeland Health Care Center. 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. Different departments also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside of Lakeland Health Care Center who may be involved in your health care after you leave, such as your physician or a subsequent healthcare provider, family members, clergy or others that we use to provide services that are part of your care.

For Payment
We may use and disclose health information about you so the treatment and services you receive at Lakeland Health Care Center may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about medical treatment you received at Lakeland Health Care Center so your health plan will pay us or reimburse you for the treatment. A bill may be sent to you or a third-party payor that may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Regular Health Care Operation
We may use and disclose health information about you for regular health care operations. These uses and disclosures are necessary to run Lakeland Health Care Center and make sure that all of our residents, patients and clients receive quality care. For example, members of the medical staff, the risk management or performance improvement director, or members of the performance 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 services we provide. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.

Business Associates
There are some services provided in our organization through contracts with business associates. Examples include certain physician, laboratory testing, billing, and record storage services that we use. When these services are contracted, we may disclose your health information to our business associates so they can perform the job we've asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.

Appointment Reminders
We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or care at Lakeland Health Care Center.

Treatment alternatives
We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. We may also disclose health information to third-parties to whom you may be referred for items such as durable medical equipment or for services such as case management for high risk patients.

Health-Related Benefits and Services
We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. You may be contacted by Lakeland Health Care Center, or by third-parties that assist us, regarding general health-related products and services and/or health-related products and services targeted to your specific health status or condition, but only where we believe those products and services may benefit you. Any communication received by you from Lakeland Health Care Center or such a third-party must identify Lakeland Health Care Center as the source of the communication, disclose whether we received any remuneration for making the communication, and contain instructions regarding how you may request that we not contact you further regarding such health-related products and services. If the communication is targeted to you, it must explain why you were targeted and how the product or service relates to your health.

Directory
We may include certain limited information about you in a directory while you are a resident or patient at Lakeland Health Care Center. Unless you notify us that you object, we may use your name, location, 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. This is so your family, friends and clergy can visit you when you are a resident or patient at Lakeland Health Care Center and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care
We may use or disclose information to notify or assist in notifying a family member, personal representative or another person who is involved in your care about your location and general condition. Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care. In addition, we may disclose 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.

Research
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Before we use or disclose health information for research, the project will have been approved through this research approval process, but we may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the health information they review does not leave Lakeland Health Care Center. We will almost always 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 Lakeland Health Care Center. Certain research projects, such as pre-project reviews and reviews of decedents' charts, are not subject to the approval process set forth in the Health Insurance Portability and Accountability Act (HIPAA). There are significant instances when a patient will not be required to give his or her specific permission for the researcher to have access to identifying information about the patient, such as pre-project reviews and retrospective chart reviews as part of approved research.

As Required By Law
We will disclose health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety
We may use and disclose health 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 such disclosure, however, would only be to someone able to help prevent the threat.

Fundraising Activities
We may use health information about you to contact you in an effort to raise money for Lakeland Health Care Center and its operations. We may disclose health information to a foundation related to Lakeland Health Care Center so the foundation may contact you in raising money for Lakeland Health Care Center. We would only release contact information, such as your name, address and phone number and the dates you received treatment or services at Lakeland Health Care Center. If you do not want to be contacted for fundraising efforts, you must notify the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center in writing.

SPECIAL SITUATIONS

Organ and Tissue Donation
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transportation of organs or tissue as necessary to facilitate organ or tissue donation and transportation.

Military and Veterans
If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation
We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Public Health Risks
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensures. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose health information about you in a response to a court or administrative order. We may also disclose 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 efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement
We may release health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at Lakeland Health Care Center; and
• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Inmates
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Coroners, Medical Examiners and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities
We may release health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Protective Services for the President and Others
We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Food and Drug Administration (FDA)
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacement.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

Although your health record is the physical property of Lakeland Health Care Center, the information belongs to you. You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy
You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes (i.e., notes from a private, group, joint or family counseling session recorded by a mental health professional such as a psychiatrist, clinical psychologist, or clinical social worker).

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by Lakeland Health Care Center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend
If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Lakeland Health Care Center.

To request an amendment, your request must be made in writing and submitted to the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center. In addition, you must provide a reason that supports your request.

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:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for Lakeland Health Care Center;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures
You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of health information about you.

To request this list or accounting of disclosures, you must submit your request in writing to the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center. Your request must state a time period which may not be longer than six years and may not include dates before February 26, 2003. Your request should indicate in what form you want the list (for example, on paper or 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 list. 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.

Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center. 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.

Right to Request Confidential Communications
You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, please contact the Clinical Resource Systems or Health Information Management departments of Lakeland Health Care Center.

CHANGES TO THIS NOTICE

We reserve the right to change our privacy practices and this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of Lakeland Health Care Center's current notice at each of our locations. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you are admitted to or register at Lakeland Health Care Center for treatment or health care services as a resident, patient or client, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Lakeland Health Care Center or with the Secretary of the Department of Health and Human Services. To file a complaint with Lakeland Health Care Center, contact Lakeland Health Care Center's Clinical Resource Systems or Health Information Management departments. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. 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. Uses and disclosures of health information are subject to additional restrictions under federal and state laws and regulations, such as those that apply to substance abuse treatment, HIV/AIDS testing and treatment, and mental health treatment.


RECEIPT FOR NOTICE OF PRIVACY PRACTICES



I, ______________________________, have received this notice. I understand I may speak to my Social Worker for further information.





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Resident/Patient


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Date

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