Nursing Home

Regulatory Guides:   45 CFR 164.520


It is the policy of this agency to disseminate a written notice to all clients that addresses its policies and procedures with respect to the treatment, use and disclosure of individually identifiable health information and with respect to the Agency’s legal duties with respect to such information (a “Notice of Privacy Practices”).

The Notice of Privacy Practices shall include all elements and statements that are required by law.  In summary, the Notice shall inform the clients about the potential uses and disclosures of their health information, as well as their rights with respect to that information, including:  (1)  a description of each of the purposes for which the Agency is permitted to disclose their health information, including, for example, treatment, payment, and health care operations; and (2)  a description of when written authorization is required before the Agency may disclose the individual’s health information in other instances.


The agency shall take reasonable measures in ensuring that  clients’ personal privacy is maintained including personal, clinical records, and medical treatments.


  1. The agency will provide the Notice of Privacy Practices at the time of admission or when service is first provided to the individual, whichever is first, and obtain written acknowledgement of receipt of the notice.
  2. A copy of the Notice of Privacy Practices will be kept in the client’s medical record.
  3. The agency will provide a copy of the Notice of Privacy Practices to clients and to any other person upon request.
  4. The agency will post a copy of the Notice of Privacy Practices in a publicly visible location and on its website at:
  5. If there is a material change in the agency’s use and disclosure policy that affects the rights of clients, legal duties imposed, or the practices of the agency, then a new Notice of Privacy Practices will be posted in the agency in a publicly visible location and on its website.  Material changes will not be implemented until a revised notice has been posted by the agency.  Updated Notices will not be provided to clients, but will be made available upon request.
  6. The agency’s Privacy Officer shall be responsible for ensuring that written notices are received and posted in accordance with this policy, and for keeping copies of the notices posted and any revisions thereto.

Notice of Privacy Practices


We have summarized our responsibilities and your rights on this first page.  For a complete description of our privacy practices, please review this entire notice.

Our Responsibilities

Our nursing agency is required to:

Your Rights

As a client of our nursing agency, you have several rights with regard to your health information, including the following:

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain.  Should or privacy practices change, we will post the changes in a publicly visible location within the agency, as well as on our website at

A copy of the revised notice will be available after the effective date of the changes upon request. 

We will not use or disclose your health information without your authorization, except as described in this notice.

If you have questions and would like additional information, you may contact our agency’s Privacy Officer (agency Administrator).

Understanding Your Health Record/Information

Each time you visit a nursing agency; a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.  This information, often referred to as your health or medical record, serves as a:

Understanding what is in your record and how your health information is used helps you to:  ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosures to others.

How We Will Use or Disclose Your Health Information

  1. Treatment.  We will use or disclose your health information for treatment purposes, including for the treatment activities of other health care providers.  For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you.  Your physician will document in your record his or her expectations of the members of your healthcare team.  Members of your healthcare team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment.  We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from our nursing agency.
  2. Payment.  We will use or disclose your health information for payment, including for the payment activities of other health care providers or payers.  For example, a bill may be sent to you or a third-party payer, including Medicare or Medicaid.  The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
  3. Health Care Operations.  We will use or disclose your health information for our regular health operations.  For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcome in your case and others like it.  This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

    In addition, we will disclose your health information for certain health care operations of other entities.  However, we will only disclose your information  under the following conditions:  (a) the other entity must have, or have had in the past, a relationship with you; (b) the health information used or disclosed must be related to that other entity’s relationship with you; and (c) the disclosure must only be for one of the following purposes:  (i) quality assessment and improvement activities; (ii) population-based activities relating to improving health or reducing health care costs; (iii) case management and care coordination; (iv) conducting training programs; (v) accreditation, licensing, or credentialing activities; or (vi) health care fraud and abuse detection or compliance.
  4. Business Associates.  There are some services provided in our organization through the use of outside people and entities.  Examples of these “business associates” include our accountants, consultants and attorneys.  We may disclose your health information to our business associates so that they can perform the job we’ve asked them to do.  To protect your health information, however, we require the business associates to appropriately safeguard your information.
  5. Directory.  Unless you notify us that you object, we may use your name, location in the agency, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.  We may also use your name on a nameplate next to or on your door in order to identify your room, unless you notify us that you object. 
  6. Notification.  We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition.  If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided us, e.g., on an answering machine.
  7. Communication with Family.  We may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health information relevant to that person’s involvement in your care or payment related to your care. 
  8. Research.  We may disclose information to researchers when certain conditions have been met.
  9. Transfer of Information at Death.  We may disclose health information to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.
  10. Organ Procurement Organizations.  Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
  11. Marketing.  We may contact you regarding your treatment, to coordinate your care, or to direct or recommend alternative treatments, therapies, health care providers or settings.  In addition, we may contact you to describe a health-related product or service that may be of interest to you, and the payment for such product or service.
  12. Fund Raising.  We may contact you as part of a fund-raising effort.
  13. Food and Drug Administration (FDA).  We may disclose to the FDA, or to a person or entity subject to the jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
  14. Workers Compensation.  We may disclose health information to the extent authorized by and to the extent necessary to comply with laws related to workers compensation or other similar programs established by law.
  15. Public Health.  As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
  16. Correctional Institution.  Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for you health and the health and safety of other individuals.
  17. Law Enforcement.  We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
  18. Reports.  Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public. 

Your Health Information Rights

Although your health record is the physical property of the nursing agency, the information in your health record belongs to you.  You have the following rights:


For More Information or to Report a Problem 

If you have questions and would like additional information, you may contact our agency’s Privacy Officer/Administrator, Jennifer Zdunic, at

If you believe that your privacy rights have been violated, you may file a complaint with us.  These complaints must be filed in writing on a form provided by our agency.  The complaint form may be obtained from the Administrator/Privacy Officer, and when completed should be returned to the Administrator/Privacy Officer.  You may also file a complaint with the secretary of the federal Department of Health and Human Services.  There will be no retaliation for filing a complaint. 

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Phone: (800) 542-8621