When you reside in a nursing home, a record of your stay is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a care plan for future care or treatment. This information, often referred to as your health or medical record, serves as a basis for planning your care and treatment, means of communication among the many health professionals who contribute to your care, legal document describing the care you receive, means by which you or a third-party payer can verify that services billed were actually provided, a tool in educating health professionals, a source of data for medical research, a source of information for public health officials charged with improving the health of the nation, a source of data for facility planning, and a marketing tool with which we can assess and continually work to improve the care we render and the outcomes we achieve. 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 help you make more informed decisions when authorizing disclosures to others.

If you consent, the nursing home is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information the information we create and obtain in providing our services to you, as described above. It also includes billing documents for those services.

• A nurse obtains treatment information about you and records it in your medical chart.
• During the course of your treatment, your physician determines that you will need medication and the pharmacist is notified as to the medications that have been ordered.

• We submit requests for payment to your health insurance company or to Medicare. The insurance company or Medicare requests information from us regarding medical care given. We will provide information to them about you and the care given.
• We may send a bill to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

• Members of the staff may use information in your health record to assess the care and outcomes 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 healthcare and services we provide.
• Student nurses or other professionals being trained in their field may have access to information in your health record as part of their training here.

The health and billing records we maintain are the physical property of the nursing home. The information in it, however, belongs to you. You have a right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our nursing home - we are not required to grant the request but we will comply with any request granted;
• Obtain a copy of the Notice of Privacy Practices for Protected Health Information by making a request at our nursing home;
• Request that you be allowed to inspect and copy your health record and billing record - you may exercise this right by delivering the request orally, however, we prefer you provide the request in writing using the form we provide to you upon request;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our nursing home using the form we provide to you upon request. (The nursing home, however, is not required to make such amendments.)
• File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our nursing home using the form we provide to you upon request. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, disclosures made to family members or friends in the course of providing care or other disclosures permitted or required by law;
• Request that communications of your health information be made by alternative means or at an alternative location by delivering the request in writing to our nursing home using the form we give you upon request; and
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our nursing home.
• Receive a paper copy of a notice received electronically upon request.

Privacy Officer, 

50 Blymyer Ave.

 Mansfield, OH 44903, 

(419) 774-5100

 in writing or in person, during normal business hours. He/she will provide you with assistance on the steps to take to exercise your rights.

You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment and health care operations purposes.

Our Responsibilities

The nursing home is required to:

• Maintain the privacy of your health information as required by law;
• Provide you with a notice as to our other duties and privacy practices as to the information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information about you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will Amend our Notice. Should this occur, we will post the amended form prominently in the facility, as well as on our web site. You will be provided with a copy, upon request.

To Request Information or File a Complaint

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to. You may also file a complaint by mailing it or E-mailing it to the Secretary of Health and Human Services.

• We cannot, and will not, require you to waive the right to file a complaint with the Secretary of health and Human Services (HHS) as a condition of receiving treatment from this nursing home.
• We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Notification - Unless you object, we may use or disclose your protected health information to notify, or assist in notifying a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family - Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Business Associates - There are some services provided in our organization through contracts with business associates. Examples include pharmacy services, mobile radiology services, certain lab tests, etc. When services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Directory - Unless you notify us that you object, we will use your name, location in the facility, 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.

Research - We may discuss information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Disaster Relief - We may use and disclose your protected health information to assist in disaster relief efforts.

Funeral Directors or Coroners - We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Food and Drug Administration (FDA) - We may disclose to 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.

Organ Procurement Organizations - Consistent with applicable law, we may disclose your protected 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.

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

Fund Raising - We may contact you as part of a fund raising effort.

Workers' Compensation - We may disclose your protected health information to the extent authorized by and the extent necessary to comply with laws relating to Workers' Compensation or other similar programs established by law.

Public Health - As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect - We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions - If you are an inmate of a correctional institution, we may disclose to the institution or its agencies, the protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement - We may disclose your protected health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate 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 residents, workers or the public.

Health Oversight - Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. This includes, for example, our annual survey/inspection from the Ohio Department of Health.

Judicial/Administrative Proceedings - We may disclose your protected health information in the course of judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Serious Threat to Health Safety - To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety or a person or the public.

For Specialized Governmental Functions - We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance programs.

Oral Communications - During the course of treatment and related billing and health care operations activities, it is to be expected that certain oral communications will take place between staff, other providers of services, residents and personal representatives.

Incidental disclosures should be expected in the course of normal business; however, all attempts will be made by the facility to minimize such disclosures. Because this is the residents' home, it should be expected that staff, and other providers will address the residents by name in public areas.

Other Uses - Other uses and disclosures besides those identified in this Notice will be made the as otherwise authorized by law or with written authorization and you may revoke the authorization as previously provided.

Website - If we maintain a website that provides information about our entity, this Notice will be on the website

Effective Date: April 14, 2003 

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Mansfield Memorial Homes ~ 50 Blymyer Avenue ~ Mansfield, Ohio 44903

(419) 774-5100