JAMES SQUARE HEALTH AND REHABILITATION CENTRE

Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made. Typically this record contains documentation regarding your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information serves as a basis for planning your care and treatment; a means of communication among the many health professionals who contribute to your care; a legal document describing the care you received; the means by which you or a third-party payer can verify that services billed were actually provided and a tool in educating health care students doing clinical training at our facility. It is also a source of information for public health officials charged with improving the health of the nation; a source of data for facility planning and marketing; a tool to help us assess and continually work to improve the care we provide as well as the outcomes 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 help you to make better informed decisions when authorizing disclosures to others.

What are your rights regarding your Protected Health Information?

Although your health record is the physical property of James Square, the information belongs to you. You have the right to: request a restriction on certain uses and disclosures of your information; obtain a paper copy of our privacy notice of information practices upon request; inspect and obtain copies of your health record; make amendments to your health record; obtain an accounting of disclosures of your health information (made for reasons other than treatment, payment or operations) and revoke your authorization to use or disclose health information except to the extent that action has already been taken. Upon your request, your social worker will provide you with information on how to request the above.

What are James Square’s responsibilities regarding your Health Information?

We are required to maintain the privacy of your health information, provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, abide by the terms of this notice and notify you if we are unable to agree to a requested restriction. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. If our protected health information practices change, we will provide you with a revised notice. We will not use or disclose your health information without your authorization, except as described in this notice.

JSNH #98 Privacy Office (Rev. 03/04/03)

PRIVACY NOTICE OF PROTECTED HEALTH INFORMATION PRACTICES

When would James Square use or disclose medical information about you?

We share your health information with the New York State Department of Health and the Federal government to aid in the administration of the Medicare/Medicaid survey and certification process in long term care facilities which helps to improve the effectiveness and quality of care given in our facility.

Below are some examples of disclosures made during our normal course of business for Treatment, Payment and Operations (TPO):

Treatment - Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your health record and used to determine the best course of treatment for you. Your attending 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, your attending physician will know how you are responding to the treatment he/she has prescribed for you.

We will provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from James Square. If you are transferred to the hospital during your stay, copies of your health record will be forwarded to the hospital to provide continuity of care.

Payment - A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, your diagnosis, procedures, and supplies used. Copies of your health record may be sent to your insurance carrier to justify your stay here at James Square and assure proper insurance coverage.

Regular Health Operations - Members of our quality improvement committee may use information in your health record to assess the care and outcomes in your case and others like it. This helps us to monitor and improve the quality of care we provide. Subject to certain requirements, information may be disclosed in the following ways and/or to:

Business Associates - There are some services provided in our organization through contacts with business associates. Examples include radiology, laboratories, and the pharmacy. When these services are contracted, we may disclose your information so they can perform the service we’ve asked them to perform and bill you or your third-party payer for services rendered. To protect your information, however, we require the business associate to appropriately safeguard your information.

Facility Directory - (Unless you notify us that you object) this means if someone comes to visit you, we will tell them the unit you are living on. We will also provide this information to the clergy upon their request.

JSNH #98 Privacy Office (Rev. 03/04/03)

PRIVACY NOTICE OF PROTECTED HEALTH INFORMATION PRACTICES

Notification - We may use or disclose information to notify or assist in notifying certain individuals regarding your care, location and general condition. These individuals may include your health care proxy, a family member or another individual you have designated as a responsible person.

Communication with family - 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.

Funeral directors - We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

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.

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

Public Health Agencies - Such as adult protective as required by law.

Law enforcement agencies - As required by law or in response to a valid subpoena.

For More Information or to Make a Complaint

If you have questions and would like additional information, you may contact our Privacy Officer at (315) 474-1561 extension 541. The Privacy Officer is available Monday - Friday 9 a.m. - 5 p.m.

If you feel your privacy rights have been violated, you may file a complaint with the Privacy Officer at the above number or speak with the Nursing Supervisor on duty.

You may also send a written complaint to the U. S. Department of Health and Human Services Office of Civil Rights. Our Privacy Officer will provide you with this address at your request. Under no circumstances will you be penalized or retaliated against for filing a complaint.

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a 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 patients, workers or the public.

JSNH #98 Privacy Office (Rev. 03/04/03)

PRIVACY NOTICE OF PROTECTED HEALTH INFORMATION PRACTICES

Acknowledgment of Receipt and Understanding of Protected Health Information Practices Notice

I have received and understand the Protected Health Information Practices Notice version effective 03/04/03.

I do give/ do not give James Square permission to list my name in the facility directory.

(Please circle)

Resident’s Name (Please Print)

Resident/Responsible Party’s Signature Relationship to Resident

Date:

Witness:

JSNH #99 Privacy Office (Revised 03/04/03)