Notice of Information Practices

If you are a resident of Quality Health of Fernandina Beach, this notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this document carefully.

We have summarized our responsibilities and your rights at the beginning of this notice. For a complete description of our information practices, please review this complete notice.

Our Responsibilities

We are required to:

• Maintain the privacy of your health information
• Provide you with this notice of our legal duties and information we collect and maintain about you; and
• Abide by the terms of this notice.

Your Rights

You have several rights with regard to your health information. Those include the right to:

• Request that we do not use or disclose your health information in certain ways;
• Request to receive communications in an alternative manner or location;
• Access and obtain a copy of your health information;
• Request an amendment to your health information, and
• Request an accounting of disclosures of your health information.

We reserve the right to change our information practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes within our building (if applicable) and on our website. A copy of the revised notice will be available after the effective date of the changes upon request.

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

If you have questions and would like additional information, you may contact the Privacy Officer at Quality Health at 904-261-0771.

Understanding Your Health Record

Each time you visit a medical provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care of treatment. This information, often referred to as you health or medical record, serves the following purposes:

• Basis for planning your care and treatment
• Communication among health professionals involved in your care
• Legal document describing the care you received
• Proof that services billed were actually provided
• A tool to educate health professionals
• A source of data for medical research
• A source of information for public health officials who oversee the delivery of health care in the United States
• A tool to measure and improve the care we give

Understanding what is in your record and how your health information is used helps you to:

• Ensure its accuracy
• Understand who, what, when, where and why others may access your health information
• Make informed decisions when authorizing disclosure to others

How We Will Use or Disclose Your Health Information

For Treatment. We will use and disclose your personal health information in providing you with treatment and services. We may disclose your personal health information to personnel who may be involved in your care, such as physicians, nurses, nurse aides, physical therapists, dietary and admissions personnel. For example, a nurse caring for you will report any change in your condition to your physician. We may also disclose personal health information to individuals who may be involved in your care after you leave the provider and are no longer in our care.

For Payment. We may use and disclose your personal health information so that we can bill and receive payment for the treatment and services you receive. For billing and payment purposes, we may disclose your personal health information to your representative, insurance or managed care, Medicare, Medicaid or another third party payer. For example, we may use your personal health information to evaluate our services, including the performance of our staff. We may use a photograph of you to identify you or for general programs such as posting on activity boards.

Business Associates. Outside people and entities provide some services to us. 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. We require the business associates to safeguard your information so that it is protected.

Directory. Unless you notify us that you object, we may use your name, location of the faciity, general condition and religious affiliation for directory purposes. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.

Notification. We may use or disclose information to notify or assist 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 him or her at the phone number that he or she has provided us, e.g. on an answering machine.

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.

Newsletters/Bulletin Boards. We may post your name and birth date on a facility board and in a facility newsletter.

Research. We may disclose information to researchers when certain conditions have been met.

Transfer of Information at Death. We may disclose health information to funeral directors, medical examiners and coroners to carry out these duties consistent with applicable law.

Organ Procurement Organizations. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.

Marketing. We may contact you regarding 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 services that may be of interest to you, and the payment for such product or service.

Fund Raising. We may contact you as part of a fund raising effort.

Food and Drug Administration (FDA). We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse with respects to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.

Worker's Compensation. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Correctional Institution. Should you be an inmate of a correctional institution for law enforcement purposes as required by law or in response to a valid subpoena.

Reports. Federal law allows a member of our work force or a business associate to release your health information to an appropriate health oversight agency, public health authority or attorney, if the work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more residents, workers or the public.

Your Health Information Rights

You have the following rights regarding your personal health information:

Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your personal health information for treatment, payment or health care operations. 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 the payment for your care.

We are not required to agree to your requested restriction (except that while you are competent you may restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

Right of Access to Personal Health Information. You have the right to inspect and obtain a copy of your medical or billing records or other written information that may be used to make decisions about your care, subject to some limited exceptions. Such records will be provided to you in the time frames established by law. We may charge a reasonable fee for our costs in copying and mailing your requested information.

We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to personal health information, in some cases you will have a right to request review of the denial.

Right to Request Amendment. 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 may deny your request for amendment in certain circumstances. If we deny your request for amendment, we will give you a written denail including reasons for the denial and the right to submit a written statement disagreeing with the denial.

Right to an Accounting of Disclosures. You have the right to request an "accounting" of our disclosures of your personal health information. This is a listing of certain disclosures of your personal health information made by us or by others on our behalf, but does not include disclosures for treatment, payment and health care operations or certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. An accounting will include, if requested, the disclosure date; the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; a brief statement of the purpose of the disclosure or a copy of the authorization request; or certain summary information concerning multiple similar disclosures. The first accounting provided within a 12 month period will be free; for further request, we may charge you our costs.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice, even if you have agreed to receive this notice electronically. You may request a copy of this notice at any time.

Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.

Right to Revoke Authorization. You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. This request must be made in writing.

For More Information or to Report a Problem

If you believe that your privacy rights have been violated, you may file a complaint in writing to us or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with us, you may contact the Privacy Officer at Quality Health of Fernandina Beach at phone number 904-261-0771.

We will not retaliate against you if you file a complaint.

If you have questions about this notice or would like further information concerning your privacy rights, please contact the Privacy Officer at Quality Health of Fernandina Beach at phone number 904-261-0771.