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Menno Haven, Inc.
Notice of Privacy Practices

TABLE OF CONTENTS

1.

Purpose of this notice.

2.

Ways we may use and disclose your protected health information (PHI) without needing to obtain your consent or authorization:
For Treatment
For Payment
For Health Care Operations

3.

We may use and disclose your protected health information for other specific purposes such as:
Business Associates - contracted services with other providers
Directory - Unless you notify us that you object
Family, friends and Power of Attorney
As permitted or required by law:
Public health activities and protected services agencies
Judicial and administrative proceeding
Law enforcement officials
Research
Coroners, medical examiners, funeral directors, organ donations
National security, military and veterans
Disaster relief
Workers’ compensation
Fundraising activities
Marketing

4.

Your written authorization is required for all other uses of protected health information

5.

Your rights regarding your protected health information:
Right to request restrictions
Right to access your protected health information
Right to request amendment to your PHI
Right to an accounting of disclosure of your PHI
Right to a paper copy of this Notice
Right to request confidential communications

6.

Changes to this Notice

7.

How to file a complaint or request further information

Notice of Privacy Practices for Menno Haven, Inc.

THIS NOTICE OF PRIVACY PRACTICES (hereinafter referred to as ‘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.

1.

Purpose of This Notice

We respect the privacy of your protected health information and are committed to maintaining our residents’ and patients’ confidentiality. This Notice applies to all information and records related to your care that the organization has received or created. It extends to information received or created by our employees, staff, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your protected health information. It also describes your rights and our obligations regarding your protected health information.

We are required by law to:

- maintain the privacy of your protected health information;
- provide to you this detailed Notice of our legal duties and privacy practices relating to your protected health information; and
- abide by the terms of the Notice that are currently in effect.

2.

Ways We May Use And Disclose Your Protected Health Information Without Needing To Obtain Your Consent Or Authorization

For Treatment. We will use and disclose your protected health information in providing you with treatment and services. We may disclose your protected health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, therapists, emergency personnel, and volunteers. For example, a nurse caring for you may report any change in your condition to your physician. We also may disclose protected health information to individuals who will be involved in your care after you leave the facility.

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

For Health Care Operations. We may use and disclose your protected health information for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use protected health information statistics to evaluate our facility’s quality control purposes services, including the performance of our staff.

3.

We May Use And Disclose Your Protected Health Information For Other Specific Purposes

We may also combine our information with other health care providers’ information to compare how we are doing and learn ways to improve our services to you. We will remove information from the data that would identify you.

Business Associates. There are some services provided in our organization through contracts with business associates. An example is laboratory tests. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associates to appropriately safeguard your information.

Directory. Unless you notify us that you object, we will include information about your name, address/location within the organization, and telephone number in our telephone directory. The directory information may be given to people who ask for you by name. We may disclose certain limited protected health information about you to a member of the clergy, such as your religious affiliation.

Family, Friends and Power of Attorney
We may disclose your protected health information to individuals, such as family, friends, or any other person you tell us that are involved in your care or who help pay for your care. Disclosures may be face-to-face, by telephone or by electronic mail. Our health professionals, using their best judgment, may disclose your protected health information to a designated representative or Power of Attorney (POA). This individual will be used by the organization as your primary contact.

As Permitted or Required By Law. We may use and disclose your protected health information to you, someone who has the legal right to act for you (personal representative), or to the Secretary of the U.S. Department of Health and Human Services, if necessary to make sure your privacy is protected, and where required by law for:

? Public health activities and protected services agencies such as reporting fraud or suspected abuse or neglect; disease outbreaks, adverse reactions to medications, or problems with health care products. We may disclose your protected health information to a health oversight agency for oversight activities authorized by law. They may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.
? Judicial and administrative proceeding in response to a court or administrative order, subpoena, discovery request, or other lawful process.
? Law enforcement officials request for the purpose to locate a missing person, a suspect, or material witness, to report criminal conduct on our premises or in an emergency to report the commission of a crime or imminent threat to health or safety of staff, residents or patients. ? Research. We may allow protected health information of residents from our organization or patients to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your protected health information may be used for research purposes only if the privacy aspect of the research has been reviewed and approved by a special Privacy Board or Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorized the use or disclosure.
? Coroners, medical examiners, funeral directors, organ procurement organizations for the purpose of identifying a deceased individual, to determine the cause of death, facilitate organ or tissue donations, or to provide funeral directors with information in order to carry out their duties.
? National security, military and veterans for purposes of intelligence, counterintelligence and other national security activities.
? Disaster Relief. We may disclose your protected health information to an organization assisting in a disaster relief effort.
? Workers’ Compensation. We may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.
? Fundraising Activities. You may be contacted for fundraising activities for the facility and its operations. You will be given the opportunity to “opt out” (not participate) if you do not want to receive any further fundraising communications.

? Marketing. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

4.

Your Written Authorization Is Required For All Other Uses Of Protected Health Information

We may use and disclose protected health information (other than described in this Notice or if not permitted or required by law) ONLY with your written Authorization on the form we will provide. You may revoke your Authorization to use or disclose protected health information at any time as long as it is in writing sent to the attention of the social services department at Menno Haven, Inc. If you revoke your Authorization, we will no longer use or disclose your protected health information as you had specified, except where we have already acted upon your Authorization.

Examples that may require your written authorization include disclosure of psychotherapy notes or use of your protected health information for marketing purposes.

5.

Your Rights Regarding Your Protected Health Information

You have the following rights regarding your protected health information at this organization:

Nursing Center Residents
Right to Request Restrictions. You have the right to request restriction or limitation on our use or disclosure of your protected health information for treatment, payment or health care operations. You also have the right to restrict or limit the protected health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.

We are required to agree to your requested restriction, unless you are being transferred to another health care institution, the release of records is required by law, if the release of information is needed to provide emergency treatment, or for payment for services rendered.

A written request for restrictions should be sent to the director of social services. We prefer that you use our form. You must tell us what information you want to limit, whether you want us to limit our use, disclosure or both, and to whom you want the limits to apply (for example, disclosures to a family member).

Right of Access to Protected Health Information. You have the right to request, either orally or in writing, your medical or billing records or other written information that may be used to make decisions about your care. We prefer that you use our form for a written request. The form may be obtained from and returned to the director of social services. We must allow you to inspect your records within 24 hours of your request. If you request copies of the record, we must provide you with copies within 2 business days of that request. We will charge a reasonable fee for copying and mailing your requested information, however, this may be waived at the discretion of the medical director.

Other Residents and Patients
Right to Request Restrictions. You have the right to request restriction or limitation on our use or disclosure of your protected health information for treatment, payment or health care operations. You also have the right to restrict or limit the protected health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.

Although we are not required to agree to your request, we will give it serious consideration. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

You must make your request for restrictions in writing to the assisted living office or health center. We prefer that you use our form. You must tell us what information you want to limit, whether you want us to limit our use, disclosure or both, and to whom you want the limits to apply (for example, disclosures to a family member).

Right of Access to Protected Health Information. You have the right to inspect and obtain a copy of your medical or billing records or other written information that may be used to make decisions about your care, subject to some limited exceptions such as psychotherapy notes.

We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied access to protected health information, in some cases you will have a right to request review of the denial. A licensed health care professional designated by the facility who did not participate in the decision to deny would perform this review.

If you want to inspect or obtain copies of your protected health information or billing records, you must submit your request in writing using the form we will provide to the assisted living office or health center. We have 30 days to respond to your request. We will charge a reasonable fee for our costs in copying and mailing your requested information, however, this may be waived at the discretion of the medical director.

All Residents and Patients
Right to Request Amendment. You have the right to request that the organization amend your protected health information if you think it is wrong or incomplete, as long as the information is kept by or for the organization. You must make your request in writing on the form we will provide, and you must state the reason for the requested amendment. The request form should be obtained from and submitted to the director of social services in the nursing center.

We may deny your request for amendment if the information:
- was not created by the organization or unless the originator of the information is no longer available to act on your request;
- is not part of the protected health information maintained by or for the organization;
- is not part of the information to which you have a right of access; or
- is already accurate and complete, as determined by the organization.

If your request is denied a written reason for the denial will be given to you and instructions on how you can give us a statement of disagreement. Your statement of disagreement may be added to your protected health information.

Right to an Accounting of Disclosure. You have the right to request a listing (accounting) of our disclosures of your protected health information, except for:
? those that we made to carry out treatment, payment and health care operations,
? those that were given to you or your personal representative,
? those that were given in accordance with an authorization signed by you or your representative, or
? those that were given out for law enforcement purposes.

To request an accounting of disclosures, you should obtain the request form from and submit your request to the director of social services in the nursing center. State a time period (it cannot be longer than six (6) years prior to the date of your request). It cannot include dates before April 14, 2003. You need to tell us in what form you want to receive the listing; for example, on paper or via electronic means.

The first accounting provided within a twelve (12) month period will be free. The organization will charge the prevailing cost for subsequent requests.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you agreed to receive this Notice electronically at our website, www.mennohaven.org. You may request a copy of this Notice at any time by contacting the social services department in the nursing center.

Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters by a certain method or at a certain location. For example, you can request that we contact you only at a certain phone number. We will accommodate all reasonable requests.

To request confidential communications, you must make your request in writing to the department responsible for your care - the nursing center contact is the director of social services; the assisted living contact is the assisted living director; and all other residents and patients should contact the health center.

6.

Changes To This Notice

We reserve the right to change the Notice and to make the revised or new Notice provisions effective for all protected health information already received and maintained by the organization as well as for all protected health information we receive in the future. We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in the Notice. We will post a copy of the current Notice in our health facilities, and have additional copies available at the social services office in each nursing center health center for all residents and patients who want to receive it.

7.

Corresponding With Complaints Or Requesting Further Information

If you believe that your privacy rights have been violated, you may file a complaint by writing or telephoning the organization and/or the Secretary of the U.S. Department of Health and Human Services at the following addresses and phone numbers:

Menno Haven, Inc.

Corporate Compliance Officer
1427 Philadelphia Avenue
Chambersburg, PA 17201
1-717-261-4169 (hotline)
1-717-262-1012

Secretary of the Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
Toll free: 1-877-696-6775

You will not be penalized in any way for filing a complaint, and filing a complaint will not interfere with your health care.

If you have any questions about this Notice or would like further information concerning your privacy rights or wish to receive an updated copy of this Notice in the future, please contact:

Social Services Office:
Menno Village 717-263-8545
Penn Hall 717-261-2043

Effective Date: April 14, 2003

Revision Date: