Elim Park Baptist Home · Notice of Privacy Practice

This notice describes how medical and/or health information about you may be used and disclosed and how you can get access to this Information. Please review it carefully. If you have any questions about this Notice, please call:

Director of Health Care Operations at (203) 272-3547, Ext. 142

The effective date of this Privacy Notice is 04/14/03.

At Elim Park Baptist Home, Inc., ("The Facility") we respect the privacy and confidentiality of your health information. This Notice of Privacy Practice ("Notice") describes how we may use and disclose your medical/health information and how you can get access to this information. This Notice applies to uses and disclosures we may make of all your health information whether created or received.

I. Our Responsibility To You By law, we are required to:

1. Maintain the privacy of your health information and to provide you with notice of legal duties and privacy practices.

2. Comply with the terms of our Notice currently in effect.
We reserve the right to change our practices and to make the new provisions effective for all health information we maintain, including both health information we already have and health information we create or receive in the future. Should we make material changes, we will make the revised Notice available to you by posting it in a clear and prominent location.

II. How We Will Use And Disclose Your Health Information For Treatment, Payment, And Health Operations. We may use and disclose your health information for purposes of treatment, payment, and healthcare operations as described below:

1. For Treatment: We may use and disclose health information to provide you with treatment and services and to coordinate your continuing care. Your health information may be used by doctors and nurses, as well as by lab technicians, dieticians, therapists, or other personnel involved in your care, both within our Facility and by healthcare providers involved in your care. For example, a pharmacist will need certain information to fill a prescription ordered by your doctor. We may also disclose your health information to persons or facilities that will be involved in your care after you leave our Facility, such as home care agencies or suppliers of medical equipment.

2. For Payment: We may use and disclose your health information so that we can bill and receive payment for the treatment and services you receive. For billing and payment purposes, we may disclose your health information to an insurance or managed care company, Medicare, Medicaid, or other third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request approval for a proposed treatment or service.

3. For Health Care Operations: We may use and disclose your health information as necessary for our internal operations, such as for general administration activities and to monitor the quality of care you receive from us. For example, we may use your health information with our Pharmacy Consultant or JCAHO to evaluate and improve the quality of care you received, for operational performance, efficiency, education, training and planning.

III. Other Uses And Disclosures We May Make Without Your Written Authorization Under the Privacy Regulations, we may make the following uses and disclosures without obtaining a written Authorization from you:

1. As Required By Law: We may disclose your health information when required by law to do so.

2. Facility Directory: Unless you object, we may use and disclose certain limited information about you in our Directory while you are a resident at our Facility. This information may include your name, your location in the Facility, telephone number, general condition, and your religious affiliation. Our Directory does not include specific medical information about you. We may disclose Directory information, except for your religious affiliation, to people who ask for you by name. We may provide the Directory information, including your religious affiliation, to a member of the clergy.

3. Persons Involved in Your Care or Payment for Your Care: Unless you object, we may disclose health information about you to a family member, close personal friend, or other persons you identify, including clergy, who are involved in your care. These disclosures are limited to information relevant to the person's involvement in your care or in arranging payment for your care.

4. Emergencies: We may use or disclose your health information as necessary in emergency treatment situations.

5. Public Health Activities: We may disclose your health information for public activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability, reporting elder abuse, neglect, domestic violence, or death.

6. Health Oversight Activities: We may disclose your health information to a health oversight agency for activities authorized by law. A health oversight agency is a state or federal agency that oversees the health care system. Some of the activities may include for example, audits, investigations, inspections, and licensure actions.

7. Advert a Serious Threat to Health or Safety: When necessary to prevent a serious threat to your health or safety, or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to someone able to help lessen or prevent the threatened harm.

8. Judicial and Administrative Proceedings: We may disclose your health information in response to a court or administrative order. We may also disclose information in response to a subpoena, discover request, or lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information.

9. Law Enforcement: We may disclose your health information for certain law enforcement purposes as follows:

  • To file reports required by law.
  • To report emergencies or suspicious deaths.
  • To comply with a court order, warrant, or other legal process.
  • To identify or locate a suspect or missing person.
  • To answer certain request for information concerning crimes.

10. Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations: We may release your health information to a coroner, medical examiner, funeral director, and, if you are an organ donor, to an organization involved in the donation of organs and tissue.

11. Research: We may use or disclose your health information for research purposes, only, if:

  • The privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board and the Board can legally waive patient authorizations otherwise required by the Privacy Regulations.
  • The researcher is collecting information for a research proposal.
  • The research occurs after your death.
  • You give written authorization for the use or disclosure.

12. Disaster Relief: We may disclose health information about you to a disaster relief organization.

13. Military and Veterans: If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may also use and disclose health information about you if you are a member of a foreign military as required by the appropriate foreign military authority.

14. National Security and Intelligence Activities; Protective Services for the Resident and Others: We may disclose health information to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of state or to conduct certain special investigations.

15. Inmates/Law Enforcement Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the institution or official for certain purposes including your own health and safety as well as that of others.

16. Workers' Compensation: We may disclose health information to comply with the laws relating to workers' compensation or similar programs.

17. Fundraising Activities: We may use limited health information such as your name, address, phone number, and the dates you received treatment or services, to contact you in an effort to raise money for the Facility.

18. Treatment Alternatives and Health-Related Benefits and Services: We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

19. Appointment Reminders: We may use or disclose health information to remind you about appointments.

20. Business Associates: We may disclose your health information to our business associates under a Business Associate Agreement.

IV. Uses and Disclosures With Your Authorization Except as described in this Notice, we will use and disclose your health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

V. Your Rights Regarding Your Health Information Listed below are your rights regarding your health information. These rights may be exercised by submitting a written request to the Facility. Each of these rights is subject to certain requirements, limitations, and exceptions. At your request, The Facility will supply you with the appropriate form to complete. You have the right to:

1. Request Restrictions: You have the right to request restrictions on our use or disclosure of your health information for treatment, payment, or healthcare operations. You also have the right to request restrictions on the health information we disclose about you to a family member, friend, or other person who is involved in your care or the payment of your care. We are required to agree to your requested restriction, with respect to release of your health information, to any individual outside of the Facility unless:

  • You are being transferred to another health care institution.
  • The release of records is required by law or third party payment.
  • To provide you with emergency care.

2. Access to Personal Health Information: You have the right to request in writing, your medical or billing records or other written information that may be used to make decisions about your care. We must allow you to inspect your records within 24 hours of your request (excluding weekends and holidays). If you request copies of the records, we must provide you with copies within two (2) working days of that request. We may charge a reasonable fee consistent with State law for our costs in copying and mailing your requested information.

3. Requested Amendments: You have the right to request an amendment of your health information maintained by the facility for as long as the information is kept by or for the Facility. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information:

  • Was not created by the Facility, unless the originator of the information is no longer available to act on your request.
  • Is not part of the health information maintained by or for the Facility.
  • Is not part of the information to which you have the right of access.
  • Is already accurate and complete, as determined by the Facility.

If we deny your request for the amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

4. Request an Accounting of Disclosures: You have the right to request an "accounting" of certain disclosures of your health information. This is a listing of disclosures made by the Facility or by others on our behalf, but does not include disclosures for treatment, payment, healthcare operations, or certain other exceptions. To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003, that is within six (6) years from the date of your request. The first accounting provided within a 12 month period will be free; for further request, we may charge you our cost.

5. Request a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. In addition, you may obtain a copy of this Notice from our web site at www.elimpark.org.

6. Requested Confidential Information: You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.

VI. Special Rules Regarding Disclosure Of Psychiatric, Substance Abuse And HIV Related Information Under Connecticut or Federal Law, additional restrictions may apply to disclosures of health information that relates to care for psychiatric conditions, substance abuse, or HIV-related testing and treatment. This information may not be disclosed without your specific written permission, except as may be specifically required or permitted by Connecticut or Federal Law. The following are examples of disclosures that may be made without your specific written permission:

  • Psychiatric Information: The Facility may disclose psychiatric information to a mental health program if needed for your diagnosis or treatment. The Facility may also disclose very limited psychiatric information for payment purposes.
  • HIV-related Information: The Facility may disclose information for purposes of treatment or payment.
  • Substance Abuse Treatment: The Facility may disclose information from a substance abuse program in an emergency.

VII. For Further Information Or To File A Complaint If you have any questions about this Notice or would like further information concerning your privacy rights, please contact: the Privacy Officer at (203) 272-3547, Ext. 142

Privacy Protection Policy for Social Security Numbers

Elim Park collects Social Security numbers in the ordinary course of its business. Elim Park has implemented reasonable technical, physical and administrative safeguards to help protect the social security numbers from unlawful use and unauthorized disclosure. All Elim Park employees are required to follow these established procedures:

  • Access to Social Security numbers is limited to those employees and service providers who have need to access the information to perform tasks for Elim Park.
  • Social Security numbers are only disclosed to third parties in accordance with Elim Park’s established policies. Elim Park will only disclose Social Security numbers to those service providers, auditors, advisors, and / or successors in interest who are legally or contractually obligated to protect them or as required or permitted by law.

If you have any questions, please contact the Privacy Officer at Elim Park-203-272-3547

If you believe that your privacy rights have been violated, you may file a complaint in writing with the Facility or with the Office of Civil Rights in the U. S. Department of Health and Human Services. We will not retaliate against you if you file a complaint. To file a complaint with the Facility, contact: the Privacy Officer at (203) 272-3547, Ext. 142. To file a complaint with the office for Civil Rights, send a written statement to Office for Civil Rights - Region I, US Department of Health and Human Services, JFK Federal Building Room 1875, Government Center, Boston, MA. 02203