To Provide Treatment. Facility may use health information to provide care and disclose health information to others who provide care, such as the attending physician and other health care professionals who are involved in care. For example, physicians involved in care will need information about symptoms in order to prescribe appropriate medications. The Facility also may disclose health care information to individuals outside of the Facility involved in care including family members, pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment. Facility may include health information in invoices to collect payment from third parties for the care given by the Facility. For example, Facility may be required by health insurers to provide information regarding health care status so that the insurer will reimburse the resident or the Facility. The Facility also may need to obtain prior approval from insurer and may need to explain to the insurer the need for health care and the services provided.

To Conduct Health Care Operations. Facility may use and disclose health information for its own operations in order to facilitate the function of Facility and as necessary to provide quality care to all of Facility's residents. Health care operations include activities such as:

• Quality assessment and improvement activities.

• Activities designed to improve health or reduce health care costs.

• Protocol development, case management and care coordination.

• Contacting health care providers and residents with information about treatment alternatives and other related functions that do not include treatment.

• Professional review and performance evaluation.

• Training programs including those in which students, trainees or practitioners in health care learn under supervision.

• Training of non-health care professionals.

• Accreditation, certification, licensing or credentialing activities.

• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.

• Business planning and development including cost management and planning related analyses and formulary development.

• Business management and general administrative activities of Facility.

• Fundraising for the benefit of Facility and certain marketing activities.

For example, Facility may use health information to evaluate its staff performance, combine health information with other Facility residents in evaluating how to more effectively serve all of Facility's residents, disclose health information to Facility staff and contracted personnel for training purposes, use health information to contact resident or families as part of general fundraising and community information mailings (unless they tell us they do not want to be contacted).

For the Facility Directory. Facility may disclose certain information about residents including name, general health status, religious affiliation and where they are located in a facility directory while they are in Facility. Facility may disclose this information to people who ask for resident by name. However, religious affiliation will only be disclosed to clergy.

If resident does not want Facility to include their information in the directory, they must notify the Social Service Director, 920-467-2401 ext. 107.

For Fundraising Activities. Facility may use information about resident including name, address and telephone number to contact resident or their family to raise money for Facility. If residents do not want Facility to contact them or their families, they must notify the Activity Director, 920-467-2401 ext. 115 and indicate that they do wish to be contacted.

For Treatment Alternatives. Facility may use and disclose health information to tell residents about or recommend possible treatment options or alternatives that may be of interest to them.

When Legally Required. Facility will disclose health information when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health. Facility may disclose health information for the following public activities and purposes:

To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.

To report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.

To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To Conduct Health Oversight Activities. Facility may disclose health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Facility, however, may not disclose health information if resident is the subject of an investigation and the investigation does not arise out of and is not directly related to resident’s receipt of health care or public benefits.

In Connection With Judicial And Administrative Proceedings. As permitted or required by State law, Facility may disclose health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Facility makes reasonable efforts to either notify resident about the request or to obtain an order protecting health information.

For Law Enforcement Purposes. As permitted or required by State law, Facility may disclose health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if the resident is a victim of a crime or in order to report a crime.

To Coroners And Medical Examiners. Facility may disclose health information to coroners and medical examiners for purposes of determining cause of death or for other duties, as authorized by law.

To Funeral Directors. Facility may disclose health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to funeral arrangements. If necessary to carry out their duties, Facility may disclose health information prior to and in reasonable anticipation, of death.

For Organ, Eye Or Tissue Donation. Facility may use or disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes. Facility may, under very select circumstances, use health information for research. Before Facility discloses any health information for such research purposes, the project will be subject to an extensive approval process. Facility will almost always request written authorization before granting access to individually identifiable health information.

In the Event of A Serious Threat To Health Or Safety. Facility may, consistent with applicable law and ethical standards of conduct, disclose health information if Facility, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to resident’s health or safety or to the health and safety of the public.

For Specified Government Functions. In certain circumstances, the Federal regulations authorize Facility to use or disclose health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker's Compensation. Facility may release health information for worker's compensation or similar programs.

Other than is stated above, Facility will not disclose health information other than with written authorization. If resident or representative authorizes Facility to use or disclose health information, resident may revoke that authorization in writing at any time.

Residents have the following rights regarding health information that Facility maintains:

Right to Request Restrictions. Resident may request restrictions on certain uses and disclosures of health information. They have the right to request a limit on Facility's disclosure of health information to someone who is involved in their care or the payment of care. However, Facility is not required to agree to the request. If resident wishes to make a request for restrictions, please contact the Administrator, 920-467-2401 ext. 103.

Right to Receive Confidential Communications. Residents have the right to request that Facility communicate with them in a certain way. For example, they may ask that Facility only conduct communications pertaining to their health information with them privately with no other family members present. If resident wishes to receive confidential communications, please contact the Social Services Director, 920-467-2401 ext. 107. Facility will not request that resident provide any reasons for their request and will attempt to honor the reasonable requests for confidential communications.

Right to Inspect and Copy Health Information. Resident has the right to inspect and copy their health information, including billing records. A request to inspect and copy records containing health information may be made to the Privacy Official, 920-467-2401 ext. 119. If resident requests a copy of their health information, Facility may charge a reasonable fee for copying and assembling costs associated with the request.

Right to Amend Health Information. Resident or their representative have the right to request that Facility amend records, if resident believes their health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Facility. A request for an amendment of records must be made in writing to the Director of Nursing, 920-467-2401 ext. 108. Facility may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if health information records were not created by Facility, if the records requested are not part of Facility's records, if the health information requested to be amended is not part of the health information resident or their representative are permitted to inspect and copy, or if, in the opinion of Facility, the records containing health information are accurate and complete.

Right to an Accounting. Resident or their representative have the right to request an accounting of disclosures of health information made by Facility for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to Privacy Official, 920-467-2401 ext. 119. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Facility will provide the first accounting resident requests during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to a Paper Copy of this Notice. Resident or their representative has a right to a separate paper copy of this Notice at any time even if resident or their representative has received this Notice previously. To obtain a separate paper copy, please contact the Social Services Director 920-467-2401 ext. 107 A resident or a resident’s representative may also obtain a copy of the current version of Facility’s Notice at its Web site, www.pinehaven.org.

Facility is required by law to maintain the privacy of health information and to provide to resident and their representative this Notice of its duties and privacy practices. Facility is required to abide by the terms of this Notice as may be amended from time to time. Facility reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Facility changes its Notice, Facility will provide a copy of the revised Notice to resident or their appointed representative. Resident or their representative has the right to express complaints to Facility and to the Secretary of Health and Human Services if resident or their representative believes that privacy rights have been violated. Any complaints to Facility should be made in writing to the Social Service Director, 920-467-2401 ext. 107. Facility encourages resident to express any concerns they may have regarding the privacy of information. Resident will not be retaliated against in any way for filing a complaint.

Facility has designated the Privacy Official at 920-467-2401 ext. 119 as its contact person for all issues regarding resident privacy and rights under the Federal privacy standards. You may contact this person at 531 Giddings Avenue, Sheboygan Falls, WI 53085.

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT Administrator, 920-467-2401 ext. 103

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