For Specific Government Functions:

We may disclose PHI of military or veterans, when requested by military command authorities, to authorized federal authorities for the purpose of intelligence, counterintelligence, and other national security activities (such as protection of the President), or to correctional institutions.

VI. Your Right Regarding Your Protected Health Information

You have the following rights concerning the use or disclosure of your PHI that we create or that we may maintain on our premises:

To Request Restrictions on Uses and Disclosures of Your Protected Health Information:

You have the right to request that we limit how we use or disclose your PHI 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 or services. For example, you could request that we not disclose to family members or friends information about a medical treatment you received.

Should you wish a restriction placed on the use or disclosure of your PHI, you must submit such request in writing. (Note: You may submit such request using our Request to Restrict the Use and Disclosure of Protected Health Information form. Copies are available in the medical records office.) The name, address, and telephone number of the person to whom the request is to be submitted is listed on the last page of this document.

We are not required to agree to your restricted request. However, should we agree, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you.

The Right to Inspect and Copy Your Medical and Billing Records:

You have the right to inspect and copy your health information, such as your medical and billing records that we use to make decisions about your care and services. In order to inspect and/or copy your health information, you must submit a written request to us. If you request a copy of your medical information, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filing your requests. We will provide you with information concerning the cost of copying your health information prior to performing such service. The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for Inspection/Copy of Protected Health Information form. Copies of these forms are available in the medical records office.

We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your health information, we will provide you written notice of our reasons of the denial and your rights for requesting a review of our denial. If such review is granted or is required by law, we will select a licensed health care professional not involved in the original denial process to review your requests and our reasons for denial. We will abide by the reviewer’s decision concerning your inspection/copy requests. You may submit your denial review requests on our Denial of Inspection/Copy of Protected Health Information form. Copies of these forms are available in the medical records office.

The Right to Amend or Correct Your Health Information:

You have the right to request that your health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request. If we approve your request, we will make such amendments/corrections and notify those with a need to know such amendments/corrections.
We may deny your request if:

Your request is not submitted in writing;
Your written request does not contain a reason to support your request;
The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
It is not part of the health information kept by or for our facility;
It is not part of the information you would be permitted to inspect and copy; and/or
The information is already accurate and complete.

If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial, and any written responses you may have relative to the information and denial process appended to your health information.

The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your amendment/correction requests on our Request for Amendment/Correction of Protected Health Information form. Copies of these forms are available in the medical records office.

The Right to Request Confidential Communications:

You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we not send any health information about you to a family member’s address. We will agree to your request as long as it is reasonably easy for us to do so. You are not required to reveal nor will we ask the reason for your request. To request confidential communications you must:

Notify us in writing;
Indicate what information you wish to limit;
Indicate whether or not you wish to limit or restrict our use or disclosure of such information; and
Identify to whom the restrictions apply (e.g., which family member(s), agency, etc).

The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for Restriction of Confidential Communications form. Copies of these forms are available in the medical records office.

The Right to Request an Accounting of Disclosures of Protected Health Information:

You have the right to request that we provide you with a listing of when, to whom, for what purpose, and what content of your PHI we have released over a specified period of time. This accounting will not include and information we have made for the purposes of treatment, payment, or health care operations or information released to you, your family, or the family directory, disclosures made for national security purposes, or any releases pursuant to your authorization.

Your request must be submitted to us in writing and must include the time period for which you wish the information (e.g., May 1, 2003 through August 31, 2003). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information. We will respond to your request within sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be notified of such extension. However, in no case will such extension exceed thirty (30) days. The first accounting you request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the twelve (12) month period. 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.

The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document. You may submit your requests on our Request for an Accounting of Disclosures of Protected Health Information form. Copies of these forms are available in the medical records office.


The Right to Receive a Paper Copy of This Notice:

You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of this information from our website (as applicable). The name, address, and telephone number of the person to whom you may obtain a paper copy of this notice is listed on the last page of this document.

VII. How to File a Complaint About Our Privacy Practices

If you have reason to believe that we have violated your privacy rights, violated our privacy policies and procedures, or you disagree with a decision we made concerning access to your PHI, etc., you have the right to file a complaint with us or the Secretary of the Department of Health and Human Services. Complaints may be filed without fear of retaliation in any form.

The name, address, and telephone number of the person to whom you may file your complaint is listed on the last page of this document. You may submit your complaint on our Privacy Practices Complaint form. Copies of these forms are available in the medical records office.
NOTICE OF PRIVACY PRACTICES

Record of Acknowledgements

Name of Resident: Date:

We are committed to preserving the privacy and confidentiality of your health information whether created by us or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your health information. We are required by state and federal regulations to abide by the privacy practices described in the notice provided to you including any future revisions we may make to the notice as may become necessary or as authorized by law.

Effective Date of This Privacy Notice

The effective date of this Privacy Notice is April 1, 2003.

Changes or Revisions to our Privacy Notice

We reserve the right to change our facility’s Privacy Notice at any time and to make revised or changed notices effective for health information we already have about you as well as any information we receive in the future about you. Should we revise or change our Privacy Notice, we will post a copy of the new or revised notice in our main lobby. You may obtain a copy of the new/revised Privacy Notice from the medical records office or download a copy from our website (as applicable).

[ ] Our Privacy Notice was revised on . [ ] No changes since the effective date listed above.

Privacy Notices, Information Restrictions, Record Amendments/Corrections, Disclosure of Information, Revoking an Authorization, Inspection and Copying of Records, Confidential Communications, Filing Complaints, Etc.

Should you have any questions concerning our facility’s privacy practices, obtaining copies of our privacy notice, requesting restrictions on the release of your information, revoking an authorization, amending or correcting your health information, obtaining a listing of the information we disclosed concerning your health information, requests to inspect or copy your medical information, requests that we communicate information about your health matters in a certain way, denial of access to your health information, filing complaints, or any other concerns you may have relative to our facility’s privacy practices, please contact:

Bill Wallen
Name of Person to Contact
3101 N. Hurstbourne Pkwy, Lou., KY 40241
Address
(502) 412-3775
Telephone Number
(502) 420-7715
Fax Number
www.baptisthomesinc.com
Website Address (as applicable)
YOU MAY ALSO FILE COMPLAINTSA WITH:

U. S. Department for Health and Human Services
200 Independence Avenue, S.W.
Washington DC 20201
(202) 691-0257
Toll Free 1-877-696-6775

Acknowledgement

I certify that I have received a copy of this facility’s Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanation provided to me and I am confident that the facility is committed to protecting my health information.

Date: My Signature:

My Printed Name:

Date: Signature of Witness:

I certify that I am the authorized representative of _________________________________________________________, and that I have received the Privacy Notice on behalf of this individual and that the facility provided me with an opportunity to review this document and ask questions to assist me in understanding his/her privacy rights. I am satisfied with the explanations provided to me and I am confident that the facility is committed to protecting health information.

Date: Signature of Representative:

Printed Name:

Relationship to Individual:

Date: Signature of Witness:

A copy of this document must be provided to you the person to whom the Privacy Notice was provided and a copy must be filed in the medical record.

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