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NOTICE OF PRIVACY PRACTICES

Immacolata Manor
2101 Hughes Road, Liberty, MO 64068
(816) 781-4332

A. Uses and Disclosures that are permitted by law

1. For Treatment. We will use and disclose your health information to provide your health care and any related services. We will also use and disclose your health information among treatment team members to coordinate and manage your health care and related services; the treatment team is defined as those who provide medical and/or habilitative services. (This does not include employment services.) This can include (but is not limited to):

• disclosure of information to a case manager who is responsible for coordinating your care;
• disclosure among Immacolata Manor staff or staff at a day program for use in planning and carrying out your daily care;
• disclosure to other health care providers (e.g. your doctors’ offices or a laboratory) working outside of Immacolata Manor.

2. For Payment. We may use or disclose your health information so that the treatment and services you receive are billed to, and payment is collected from, your health plan or other third party payer. For example, we may disclose your health information to permit your health plans or medical billing agencies to take certain actions before approving or paying for your services. These actions may include:

• Making a determination of eligibility or coverage for health insurance;
• Reviewing your services to determine if they were medically necessary;
• Reviewing your services to determine if they were appropriately authorized or certified in advance of your care; or
• Reviewing your services for purposes of utilization review, to ensure the appropriateness of your care, or to • justify the charges for your care.

For example, your health plan may ask us to share your health information in order to determine if the plan will approve additional visits to your therapist.

3. For Health Care Operations. We may use and disclose health information about you for our internal operations. These uses and disclosures are necessary to run our organization and make sure that our you receive quality care. These activities may include, for example, quality assessment and improvement, reviewing the performance or qualifications of our staff, training our staff, licensing, accreditation, business planning and development, and general administrative activities.

B. Uses and Disclosures that May Be Made without Your Authorization, but for which You Will Have an Opportunity to Object

1. Directory of Guardians/Family Advocates. The Directory listing of guardians and family members will only be used by Immacolata Manor staff and the Immacolata Manor Auxiliary for mailings and telephone contact. If you wish to restrict the information included (name of resident/participant and name, address, telephone number and relationship of guardians/family advocates), that restriction will apply only to the Directory given to the Auxiliary, not to the one used by Manor staff.
2. Manor Activities. Consumers who take part in Immacolata Manor’s services may be introduced by name within the community, or to guests on the property, in the course of daily activities. For example, participants who volunteer in a community organization may be introduced to individuals within that organization, or a resident may be introduced to the clergy and other parishioners when attending church activities. In such instances, the Minimum Necessary standards are strictly observed; information disclosed will be appropriate to the activity only. At no time will any information such as past, present or future physical or mental health or condition, medications or other healthcare-related information be disclosed in Manor or community activity settings.
3. Volunteer Organizations. A number of volunteers participate in events throughout the year at Immacolata Manor. At times (particularly the Christmas season) volunteers will host parties or even provide gifts for our consumers. When appropriate, we will provide first names, clothing sizes, hobbies and interests, or other such information to these volunteers in order to help them carry out their activities. Again, Minimum Necessary standards will apply in all volunteer situations.
4. Contacting Family Members in Case of Emergency. If you are in an emergency situation and we are unable to gain your authorization (or that of your guardian, if applicable), we may disclose your health information to a family member so that such person may assist in your care. In this case we will determine whether the disclosure is in your best interest and, if so, only disclose information that is relevant to participation in your care.
5. Notifying appropriate persons about your location, general condition, or death. For example, we may need to inform your employer of illness or injury, or inform family members (non-guardians) of your location.

C. Uses and Disclosures that May be Made without Your Authorization or Opportunity to Object

1. Emergencies. We may use and disclose your health information in an emergency treatment situation. For example, we may provide your health information to a paramedic who is transporting you in an ambulance.

2. Communication Barriers. We may use and disclose your health information if one of our staff attempts to obtain consent from you, but is unable to do so due to substantial communication barriers. However, we will only use or disclose your health information if the staff determines in his/her professional judgement that, absent the communication barriers, you likely would have consented to use or disclose information under the circumstances.

3. Research. We may disclose your health information to researchers when their research has been approved by the Board of Directors of Immacolata Manor and the Department of Mental Health Professional Review Committee, and there are established protocols to ensure the privacy of your health information.

4. As Required by Law. We will disclose health information about you when required to do so by federal, state or local law, including disclosures for national security.

5. To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person. Under these circumstances, we will only disclose health information to someone who is able to help prevent or lessen the threat.

6. Public Health Activities. We may disclose health information about you as necessary for public health activities including, for example, disclosures to:

• report to public health authorities for the purpose of preventing or controlling disease, injury or disability;
• conduct public health surveillance;
• notify a person who may have been exposed to a communicable disease or who is at risk of contracting or spreading a disease or condition;
• notify the appropriate government agency if we believe you have been a victim of abuse, neglect or domestic violence.

7. Government Oversight Activities. We may disclose health information about you to a government oversight agency for activities authorized by law. Oversight agencies include government agencies that oversee the health care system, government benefit programs such as Medicare, Medicaid, HUD, the DDRB or Vocational Rehabilitation, or other government programs regulating health care and civil rights laws.

8. Disclosures in Legal Proceedings. We may disclose health information about you to a court or administrative agency when a judge or administrative agency orders us to do so. We also may disclose health information about you in legal proceedings without your permission or without a judge or administrative agency’s order when you are a party to a legal proceeding and we receive a subpoena for your health information.

9. Law Enforcement Activities. We may disclose health information to a law enforcement official for law enforcement purposes when:

• a court order, subpoena, warrant, summons or similar process requires us to do so; or
• the information is needed to identify or locate a suspect, fugitive, material witness or missing person; or
• we report criminal conduct occurring on the premises of our facility; or
• we determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by you against yourself or another person; or
• the disclosure is otherwise required by law.

We may also disclose health information about a client who is a victim of a crime, without a court order or without being required to do so by law. However, we will do so only if the disclosure has been requested by a law enforcement official and the victim agrees to the disclosure or, in the case of the victim’s incapacity, the following occurs:

• the law enforcement official represents to us that (i) the victim is not the subject of the investigation and (ii) an immediate law enforcement activity to meet a serious danger to the victim or others depends upon the disclosure; and
• we determine that the disclosure is in the victim’s best interest.

10. Medical Examiners, Funeral Directors or Organ Procurement Organizations. We may provide health information about our consumers to a medical examiner. Medical examiners are appointed by law to assist in identifying deceased persons and to determine the cause of death in certain circumstances. We may also disclose health information about our consumers to funeral directors as necessary to carry out their duties, or to organ procurement organizations if you have signed a donation card.
11. Workers’ Compensation. We may disclose health information about you to comply with the state’s Workers’ Compensation Law.

III. Uses and Disclosures of Your Health Information with Your Permission

Uses and disclosures not described in Section II of this Notice will generally only be made with your written permission, called an “authorization.” You have the right to revoke an authorization at any time. If you revoke your authorization we will not make any further uses or disclosures of your health information under that authorization, unless we have already taken an action relying upon the uses or disclosures you have previously authorized.

IV. Your Rights Regarding Your Health Information

A. Right to Inspect and Copy
You have the right to request an opportunity to inspect or copy health information used to make decisions about your care – whether they are decisions about your treatment or payment for your care. Usually, this would include medical, program and billing records, but not psychotherapy notes.
You must submit a “Request for Access to PHI Records” form to our Privacy Officer at the address given on this Notice. If you request a copy of the information, we may charge a fee for the cost of copying, mailing and supplies associated with your request.
We may deny your request to inspect or copy your health information in certain limited circumstances. In some cases, you will have the right to have the denial reviewed by a licensed health care professional not directly involved in the original decision to deny access. We will inform you in writing if the denial of your request may be reviewed. Once the review is completed, we will honor the decision made by the licensed health care professional reviewer.

B. Right to Amend
For as long as we keep records about you, you have the right to request us to amend any health information used to make decisions about your care – whether they are decisions about your treatment or payment of your care. Usually, this would include clinical and billing records, but not psychotherapy notes.
To request an amendment, you must submit a “Request for Amendment of PHI” form to our Privacy Officer at the address given on this Notice and tell us why you believe the information is incorrect or inaccurate.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend health information that:

• was not created by us, unless the person or entity that created the health information is no longer available to make the amendment;
• is not part of the health information we maintain to make decisions about your care;
• is not part of the health information that you would be permitted to inspect or copy; or
• is accurate and complete.

If we deny your request to amend, we will send you a written notice stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with the denial. If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request.
If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written statement and the rebuttal (as well as the original request and denial) to all future disclosures of the health information that is the subject of your request.
C. Right to an Accounting of Disclosures
You have the right to request that we provide you with an accounting of disclosures we have made of your health information. An accounting is a list of disclosures. However, this list will not include certain disclosures of your health information; for example, those we have made for purposes of treatment, payment, and health care operations.
To request an accounting of disclosures, you must submit a “Request for an Accounting of Disclosures” form to the Privacy Officer at the address given on this Notice. The request should state the time period for which you wish to receive an accounting. This time period should not be longer than six years and not include dates before April 14, 2003.
The first accounting you request within a twelve-month period will be free. For additional requests during the same 12 month period, we will charge you for the costs of providing the accounting. We will notify you of the amount we will charge and you may choose to withdraw or modify your request before we incur any costs.
D. Right to Request Restrictions
You have the right to request a restriction on the health information we use or disclose about you for treatment, payment or health care operations. To request a restriction, you must either include it in the Acknowledgement form, or request the restriction in writing addressed to the Privacy Officer at the address given on this Notice. The Privacy Officer will ask you to sign a new Acknowledgement form which includes the restrictions if they are approved.
We are not required to agree to a restriction that you may request. If we do agree, we will honor your request unless the restricted health information is needed to provide you with emergency treatment, or disclosure is required by law.
E. Right to Request Confidential Communications
You have the right to request that we communicate with you about your health care only in a certain location or through a certain method. For example, you may request that we contact you only at work or by e-mail.
To request such a confidential communication, you must make your request in writing to the Privacy Officer at the address given on this Notice. We will accommodate all reasonable requests. You do not need to give us a reason for the request, but your request must specify how or where you wish to be contacted.
F. Right to a Paper Copy of this Notice
You have the right to obtain a paper copy of this Notice of Privacy Practices at any time. To obtain a paper copy, contact our Privacy Officer at 2101 Hughes Road, Liberty, MO, 64068.

V. Complaints
If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Complaint Officer at the address given on this Notice. All complaints must be submitted in writing; our Privacy Officer will assist you with writing your complaint if you request such assistance. If you are not satisfied with our response, or if you feel the violation is serious enough, you may also file a complaint with the Office of Civil Rights (Center for Medicare and Medicaid Services), the enforcement arm of the Department of Health and Human Services. To do so, you may call toll free at 1-866-627-7748 (1-866-788-4989 TTY) or visit the website at http://www.hhs.gov/ocr/hipaa. We will not retaliate against you for filing a complaint.

VI. Changes to this Notice
We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at our main office and at each site where we provide care. You may also obtain a copy of the current Notice of Privacy Practices by calling us at (816) 781-4332 and requesting that a copy be sent to you in the mail or by asking for one any time you are at our offices.

VII. Who Will Follow this Notice
This Notice of Privacy Practices will be followed by all of Immacolata Manor and its Business Associates. These are entities which use and disclose limited PHI or have access to PHI in order to carry out services involved in the operations of Immacolata Manor, and will be required to sign a Business Associate Agreement in compliance with the Health Insurance Portability and Accountability Act. Business Associates may include: Computer Service Providers, CARF (accreditation service), Billing Contractors, Insurance Companies if a claim should be filed, Realtors (for ISLs), Dieticians, or Auditors.