This Notice of Privacy Practices applies to the affiliated covered entities and licensed facility of Pine Haven Christian Home, Inc. (collectively referred to in this document as, "Pine Haven"). Pine Haven is required by law to maintain the privacy of your health information, abide by the terms of this Notice, and to provide to you and your representative this Notice of its duties and privacy practices concerning your health care information. We will follow the privacy practices described in this notice. If you have any questions about any part of this Notice or if you want more information about the privacy practices of Pine Haven, please contact the Privacy Officer, 220 Haven Dr., Sheboygan Falls, WI or at (920) 550-5689. We reserve the right to change the privacy practices described in this notice. We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. We maintain our current privacy practices on our website.
The following categories describe the ways that Pine Haven may use and disclose your health information. For each type of use and disclosure, we will explain what we mean and present some examples.
To Provide Treatment: We may use your health information to provide care to you and disclose your health information to others who provide care to you, such as your attending physician and other health care professionals who are involved in your care. For example, physicians involved in your care will need information about symptoms in order to prescribe appropriate medications.
Pine Haven also may disclose your health care information to individuals outside of the facility involved in your care including family members, pharmacists, suppliers of medical equipment, or other health care professionals. If another provider requests your health information and they are not providing care and treatment to you, we will request an authorization from you before providing your information.
To Obtain Payment: We may use or disclose your health information to obtain payment for your health care services. For example, we may use your information to send a bill for your health care services to your insurer.
In order for an insurance company to pay for your treatment, we must submit a bill that identifies you, your diagnosis (es), and the treatment provided to you.
To Conduct Health Care Operations: We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning, and compliance with the law. For example, we may use your information to determine the quality of care you received and evaluate staff performance, combine your health information with other Residents in evaluating how to more effectively serve all the Facility’s Residents, disclose your health information to Facility staff, and contracted personnel for training purposes. If the activities require disclosure outside of our health care organization, we will request your authorization before disclosing that information.
Health care operations include activities such as quality assessment, protocol development, case management, and care coordination, professional review and performance evaluation, training programs in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing, or credentialing activities, reviews and audits, business planning, development, management, fundraising, and certain marketing activities.
The following categories describe the ways that Pine Haven may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and present examples.
As Required or Permitted by Law: We may use or disclose your health information when it is required to do so by any federal, state, or local law. For example: We may have to report abuse, neglect, domestic violence or certain physical injuries, or to respond to a court order.
Public Health: We may release your health information to local, state, or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases and reporting problems with products and reactions to medications to the Food and Drug Administration.
Victims of Abuse, Neglect, or Violence: We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect, or violence related to the elderly.
Health Oversight Activities: We may disclose your health information by law to conduct audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system so they can monitor, investigate, inspect, discipline, or license those who work in the health care system or for government benefit programs. We may not disclose your health information if you are the subject of an investigation and the investigation is not directly related to your receipt of health care of public benefits.
Judicial and Administrative Proceedings: We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order. Under most circumstances when the request is made through a subpoena, a discovery request or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes. Under some limited circumstances we will request your authorization prior to permitting disclosure.
Coroners, Medical Examiners, Funeral Directors: We may disclose your health information to coroners and medical examiners for purposes of determining cause of death or for other duties, as authorized by law and to funeral directors so they can carry out funeral preparation activities.
Cadaveric, Organ, Eye, or Tissue Donation: We may disclose your health information to individuals involved with obtaining, storing, or transplanting organs, eyes, or tissues for donation purposes.
Research: Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to determine whether a certain treatment is working better than another.
Business Associates: Pine Haven may disclose your health information to our business associates if health information is necessary for them to perform functions or provide services to Pine Haven. Pine Haven requires our business associates to agree in writing to protect the privacy of your health information and to use and disclose your health information only as specified in that written agreement.
Facility Directory: Unless you object, we may use your health information, such as your name, location in our facility, your general health condition, and your religious affiliation for our directory. It is our duty to give you enough information so you can decide whether or not to object to release of this information for our directory.
If you do not object and the situation is not an emergency, and disclosure is not otherwise prohibited by law, we are permitted to release your information under the following circumstances:
For Fundraising Activities: In support of our charitable mission, Pine Haven may use information about you (e.g., demographic information, dates of health care provided, the affiliated covered entity that provided services, outcome information and health insurance status) to contact you or your family to raise money for Pine Haven. You may choose to "opt-out" from receiving these fundraising communications by notifying Pine Haven at (920) 550-5256 that you do not wish to be contacted.
Health Information Exchange: Pine Haven may participate in one or more health information exchanges (a shared system of electronic health care record access among different providers) with other health care organizations to facilitate access to health information that may be relevant to your care. For example, if you are admitted on an emergency basis to a hospital that participates in a health care exchange and you cannot provide important information about your condition, the hospital could use the health information exchange to access the health information Pine Haven maintains about you to treat you at the hospital.
In the Event of a Serious Threat to Health and Safety: We may, consistent with applicable law and ethical standards of conduct, disclose your health information, if we, in good faith, believe that such release is necessary to prevent or minimize a serious and approaching threat to your health or safety or to the health or safety of the public.
Specialized Government Functions: In certain circumstances, the federal regulations authorize Pine Haven to disclose your health information to facilitate specified government functions relating to military, veterans, national security and intelligence activities.
Worker’s Compensation: We may release your health information for Worker’s Compensation or similar programs.
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing, and the sale of protected health information require your authorization. When you do authorize use or disclosure of information, we will make reasonable efforts to limit the health information to the minimum necessary to accomplish the intended purpose of the use or disclosure. The minimum necessary standard does not apply to disclosures to health care providers for treatment, disclosures made to the Resident, disclosures made pursuant to an authorization, disclosures made to the Department of Health and Human Services, disclosures required by law, and disclosures required for compliance with HIPAA.
If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose your health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission
Inspect and Copy Your Health Information: You have the right to inspect and copy your health information, including billing records. You have the right to request that the copy be provided in an electronic form or format. If the form and format are not readily producible, then we will work with you to provide it in a reasonable electronic form or format. Your request for inspection or access must be submitted in writing to the Privacy Officer. In addition, we may charge a reasonable fee to cover our expenses for copying your health information.
Request to Correct Your Health Information: You have a right to request that we amend your health information that you believe is incorrect or incomplete. For example, if you believe that a diagnosis listed in your record is not correct, you may request the information be corrected. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must make the request in writing to the Privacy Officer. You must also provide a reason for the request.
Request Restrictions on Certain Uses and Disclosures: You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. For example, you may want to limit the health information provided to someone who is involved in your care or the payment of your care. However, we are not required to agree to your request except we will agree to restrict disclosures of health information to a health plan when you have paid for the item/service in full and out of pocket. You must submit a request for restriction, in writing to the Privacy Officer.
Receive Confidential Communications of Health Information: You have the right to request that we communicate your health information to you in different ways or places. For example, that we conduct communications pertaining to your health information with you privately with no other family members present. You must submit your request in writing to the Privacy Officer and the request must specify how you wish communications to be shared. You do not need to provide any reasons for your request and we will attempt to honor your reasonable requests for confidential communications.
Receive a Record of Disclosures of Your Health Information: You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made. For example, you may request a list that indicates all the disclosures made from your health care record in the past six months. To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer. We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.
Obtain a Paper Copy of this Notice: Upon your request, you may at any time, receive a paper copy of this Notice. To obtain a paper copy of this Notice, contact the Privacy Officer.
Notified of a Breach: We are required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.
Complaint: If you or your representative believe your rights have been violated, you have the right to file a complaint to the Privacy Officer at 220 Haven Dr., Sheboygan Falls, WI 53085 or at (920) 550-5689 and we will provide you with any needed assistance. We request you file your complaint in writing so that we may better assist in the investigation of your complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. There will be no retaliation against you in any way for filing a complaint.
Contact Person: If you have any questions or concerns regarding your privacy rights or the information in this Notice, please contact the Privacy Officer at 220 Haven Dr., Sheboygan Falls, WI 53085, or at (920) 550-5689.
EFFECTIVE DATE: April 14, 2003
REVISIONS: September 23, 2013, January 19, 2022, June 20, 2023
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