Broadlawn Manor Nursing Rehabilitation Center

Effective: April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Long Island Home operates Broadlawn Manor Nursing & Rehabilitation Center (including the adult day care program).  This notice applies to residents of either facility/program.  In this notice, “LIH” means Long Island Home as the operator of the facility/program.

LIH uses and discloses your health information as described in this notice.  LIH may not use your health information for other reasons unless you have authorized us in writing to do so.  You may revoke an authorization at any time by following the instructions in your copy of the authorization.

HOW LIH MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

In general, your health information is contained in a medical record that is the physical property of LIH.  In accordance with your general written consent, LIH uses and discloses your health information for the following purposes:

Treatment.

LIH uses your health information to provide you with medical treatment or services.  Doctors, nurses, and others providing care to you will collect information about you, including:

• general information, such as your age, sex, height, or weight
• your medical history, such as vaccinations, prior surgeries or episodes of illness, or prior periods of hospitalization, and
• specific information about any health problems you may presently have, such as a “chief complaint” and any presenting signs and symptoms

This information will be recorded in your medical record and used by your health care providers to determine what medical treatment, if any, you should receive.  LIH may also disclose your information to other health care providers treating you.  For example, if you are transferred to a hospital for inpatient treatment, LIH may disclose information to the hospital to help the hospital treat you.

Payment

LIH uses and discloses your health information to receive payment for services we have provided to you.  Unless you are paying for your care directly, LIH will submit a “claim” containing information about you to a third-party payor (such as Medicaid or a private insurance company).  The claim may include your name, identification number, your diagnosis, and a specific description of the treatment we provided and supplies we used to treat you.  Sometimes a payor asks us to send medical records to support a claim.  LIH limits disclosures for payment purposes to the minimum necessary to obtain payment.

Health Care Administration.

LIH may use and disclose your health information for administrative purposes.  One example is quality improvement.  LIH quality improvement personnel may discuss particular residents and the care the resident has received in order to

• evaluate the performance of LIH care providers and support staff
• assess the quality of your care and outcomes in your cases and similar cases, and
• learn how to improve our facilities and services

We do not routinely disclose health information to outside parties for administrative purposes, but it does sometimes happen.  LIH limits disclosures for administrative purposes to the minimum necessary to accomplish the purpose.  We also obtain reasonable assurances from those to whom the information is disclosed that they will not use your health information inappropriately.

Disclosures for Other Purposes.

LIH may use or disclose your health information for the other purposes described below.  We will obtain your consent or authorization whenever it is required prior to making any of the following disclosures.

Appointments.

LIH may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising.

LIH may contact you for fundraising events for LIH.

Disclosures Required by Law.

LIH may be required to disclose health information about you when required by law, including, for example, mandatory reporting (such as reporting suspected abuse or neglect) or compliance with a court order or, under certain circumstances, a subpoena.

Public Health Matters.

 LIH may use or disclose your health information to assist public health authorities or other legal authorities to prevent or control disease or injury, or to conduct a public health investigation.

Health Oversight Activities.

LIH may use or disclose your health information to government entities responsible for overseeing the health care system, including agencies responsible for licensure and certifications of health care providers, agencies responsible for administering government health care programs, and agencies responsible for investigating health care fraud and financial abuse.

Other Law Enforcement Purposes.

LIH may use or disclose your health information to law enforcement agencies for the purpose of identifying or locating a suspect, witness, or missing person.

Decedents.

LIH may disclose your health information to a funeral director or coroner if necessary.

Organ/Tissue Donation.

If you are an organ, eye, or tissue donor, LIH will use and disclose your health information as necessary to accommodate your donation wishes.

Research.

LIH may use your health information in an approved research project.  The U.S. Food and Drug Administration and Department of Health and Human Services maintain comprehensive rules that apply to medical research and contain stringent standards protecting resident’s privacy rights.  LIH must follow these rules when undertaking medical research.

Personal Health and Safety.

LIH may disclose your health information if necessary to avert a serious threat to the health or safety of you or any other person.

Government Functions.

LIH may disclose your health information for specialized government functions such as for intelligence, counter-intelligence, or national security reasons, to protect the President of the United States or other heads of state, or to report to various branches of the armed services (if you are or are formerly a member of the armed services) that may require use or disclosure of your health information.

Workers Compensation.

LIH may disclose your health information in order to comply with New York’s Workers’ Compensation Law.

YOUR HEALTH INFORMATION RIGHTS

You have the right to

• ask LIH to restrict certain uses and disclosures of your health information (we do not have to agree to any requested restriction)
• request communications of your health information by alternative means or at alternative locations  (for example, to a son or daughter)
• see and obtain a copy of your health record (we may charge a fee for copying)
• make changes to or add information or an explanation to your health record
• find out what disclosures of your health information have been made (LIH is not required to log every disclosure, only those meeting certain criteria under federal privacy rules)

COMPLAINTS

You may complain to us and/or to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.  To file a complaint with us, please contact the Privacy Officer identified at the end of this form.  LIH cannot retaliate against you for filing a complaint.

OUR OBLIGATIONS TO YOU

LIH is required to

• maintain the privacy of your health information
• provide you with this notice of its legal duties and privacy practices with respect to your health information
• abide by the terms of this notice, unless it has been replaced by an updated notice
• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed
• accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations

LIH reserves the right to change the privacy practices described in this notice and to make the new provisions effective for all protected health information it maintains, including information obtained prior to the effective date of the new notice.  Revised notices will be posted on our website and at all major entrances to our facilities, as well as in administrative areas where posting the notice would be appropriate.  You may also obtain a revised notice by asking us for one.

You have the right to obtain a paper copy of this notice, especially if you are viewing this notice electronically and even if you have asked us to send you this notice electronically.

If you have any questions or complaints, please contact:

            Privacy Officer
            400 Sunrise Highway
            Amityville, NY  11701
            (631) 264-4000     Extension 6980