Notice of Privacy Practice

This notice describes how your medical information may be used and disclosed (provided to others) and how you can get access to this information. Please review this notice carefully.

This Notice of Privacy Practices explains how this Facility, its nursing staff members, employees, Medical Director, volunteers, and others may use and provide your Protected Health Information (called PHI) to others for treatment, payment, and health care "operations" as described below, and for other purposes allowed or required by law.

I. OUR RESPONSIBILITIES:

This Facility takes the privacy of your health information seriously. We are required by law to keep your health information private and provide you with this Notice of Privacy Practices. We will act according to the terms of this Notice. We reserve the right to change this Notice of Privacy Practices and to make any new practices effective for all Protected Health Information that we keep. Any changes made to the Notice of Privacy Practices will be posted in the Resident Admission Area, in our Facility''s entrance, posted on our Web site www.deserethealth.com and given to you at your next appointment.

II. WHAT IS "PROTECTED HEALTH INFORMATION" (PHI)?

Protected Health Information (PHI) is information about a Resident's age, race, sex, and other personal health information that may identify the Resident. The information relates to the Resident's physical or mental health in the past, present, or future, and to the care, treatment, and services needed by a Resident because of his or her health.

III. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE?

Health care operations: includes activities such as discussions between Nursing Home/Adult Care Home staff and other health care providers; evaluating and improving quality; making travel arrangements to and from the Facility; reviewing the skills, competence, and performance of health care staff; training future health care staff; dealing with insurance companies and government payors and private payors; carrying out nursing reviews, quality assurance, and auditing; collecting and studying information that could be used in legal cases; and managing business functions.

IV. HOW IS MEDICAL INFORMATION USED?

The Facility uses medical records to record health information, to plan care and treatment, and to carry out routine health care functions. For example, your insurance company may need us to give them procedure and diagnosis information to bill for nursing treatment we provide. Other health care providers or health plans reviewing your records must follow the same privacy laws and rules that the Facility is required to follow.

V. EXAMPLES OF HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

Medical information may be used to show that a Resident needs certain care, treatment, and services (such as lab tests, prescriptions, treatment plans, and research study requirements).

• We will use medical information to plan treatment.
• We may disclose Protected Health Information to another provider for treatment (such as, referring doctors, specialists, etc.).
• We may send claims to your insurance company containing medical information.
• We may use the emergency contact information you gave us to contact you if the address we have on record is no longer correct.
• We may contact you to discuss other possible nursing benefits or benefits related to health that might interest you.

VI. WHY DO I HAVE TO SIGN A CONSENT FORM?

When you sign the consent form, you are giving the Facility permission to use and disclose (provide to others) Protected Health Information for treatment, payment, and health care operations, as described above. This permission does not include psychotherapy notes (defined in Section VII below), psychosocial information (defined in Section VIII below), alcoholism and drug abuse treatment records, and other privileged categories of information, all of which require a separate permission. You will need to sign a separate consent form to have Protected Health Information given out for any reason other than treatment, payment, or health care operations or as required or permitted by law.

VII. WHAT ARE PSYCHOTHERAPY NOTES?

Psychotherapy notes are notes recorded (in any form) by a mental health professional for the purpose of studying a conversation that took place during a private counseling session. This session can be with a single person, a group, or a family. Conversation notes from a counseling session are separated from the rest of the Resident''s medical record. Psychotherapy notes do not include: notes about which medicines you are taking or how those medicines affect you; the start and stop times of counseling sessions; the types of treatment you are given; how often treatments are given; the results of clinical tests; and any summary of the following items: diagnosis, functional state, the treatment plan, symptoms, expected outcome, and progress to date.

VIII. WHAT IS PSYCHOSOCIAL INFORMATION?

Psychosocial information is information given to your social worker about your family's social history and counseling services you have received.

IX. WHY DO I HAVE TO SIGN A SEPARATE PERMISSION FORM?

To provide Resident Protected Health Information to other people for any reason other than treatment, payment, and health care operations (described above) or as required or permitted by law, we must have a permission from known as an Authorization Form signed by the Resident or the Resident's parent or legal guardian. This form clearly explains how they wish the information to be used and disclosed. The following are some examples of information that require separate permission before we can release it:

• Psychotherapy notes
• Information and photographs shared with the Facility for any marketing and public relations activities
• Information used in scientific and educational publications, presentations, and materials related to the work at the Facility.

X. CAN I CHANGE MY MIND AND WITHDRAW PERMISSION FOR THE FACILITY TO DISCLOSE PHI?

You may change your mind and withdraw (revoke) permission, but we cannot take back information that has been released up to that point. Permission cannot be withdrawn if (1) the information is needed to maintain the integrity of any research study, or (2) if the permission was originally given to obtain insurance coverage or government payor or any other payor. All requests to withdraw permission for uses and disclosures of PHI should be made in writing. The request should be submitted to the Business Office Manager, which will then forward this information to the Privacy Officer/ Sr VP of Regulatory Compliance.

XI. BEING LISTED IN THE NURSING HOME/ADULT CARE HOME DIRECTORY

The Facility may include certain limited information about the Resident in our Nursing Home/Adult Care Home directory while the Resident is in the Nursing Home/Adult Care Home. This information may include the Resident's name, location in the Nursing Home/Adult Care Home, general condition (for example, good, fair, etc.), and religion. The Nursing Home/Adult Care Home may give this information to members of the clergy. The Nursing Home/Adult Care Home may give this information (except your religion) to other people who ask for the Resident by name. For example, if someone calls the Facility and asks for the Resident by name, the Facility will attempt to connect the caller to the Resident's Nursing Home/Adult Care Home room telephone. If you do not wish to be in the Nursing Home/Adult Care Home Directory, please inform Business Office Manager and request a Directory Opt Out Form from Resident Admission Forms.

XII. SHARING INFORMATION WITH THE FACILITY BUSINESS ASSOCIATES

Some services at the Facility are provided through contracts with business associates or business partners. Examples include scheduling travel to or from the Facility. When these services are contracted, we may disclose the minimum necessary amount of your health information to the business partner that they need to perform the job we have hired them to do. To protect your health information, we legally require our business associates and business partners to follow the same privacy laws that the Facility must follow.

XIII. WHEN IS MY CONSENT NOT REQUIRED?

The law requires that some information may be disclosed without your permission during the following times:

• In an emergency
• When communication or language is very limited
• When required by law
• When there are risks to public health
• To conduct health oversight activities
• To report suspected abuse or neglect or exploitation of finances
• To certain government agencies who monitor activity
• In connection with court or government cases
• For law enforcement purposes
• To coroners and funeral directors and for organ donation
• If health or safety is seriously threatened

XV. YOUR PRIVACY RIGHTS

The following explains your rights with respect to your Protected Health Information (called PHI) and a short description of how you may use these rights.

1. You have the right to review and to ask for a copy of your health information. This means that except as explained below, you may review and get a copy of your PHI that is contained in a "designated record set" as long as we keep the PHI. A designated record set contains medical and billing records and any other records that the Facility uses to make decisions about your health care. You may not read or be given a copy of psychotherapy notes; information collected for use in a civil, criminal, or administrative action, or court case; and certain PHI that is protected by law. In some situations, you may have the right to have this decision reviewed. Please contact the Business Office Manager if you have questions about access to your medical record. If needed and at your request, the Facility may provide an electronic copy of your record if the Facility is able to do so. A fee will be charged for requesting a copy of your health or medical records for everyone except Medicaid residents.

2. You have the right to request that access to your health information be limited. This means you may ask us to restrict or limit the medical information we use or disclose for treatment, payment, or health care operations (described above). The Facility is not required to agree to a restriction that you ask for. We will tell you if we reject your request. If we do agree to the requested restriction, we will not violate that restriction unless it must be violated to provide emergency treatment. You may request a restriction by contacting the Business Office Manager.

3. You have the right to request to receive private communications in another way or at other locations. Presently we will deliver in a sealed envelope private communications to you. However, we will agree to reasonable requests. To carry out the request, you can ask to have it mailed to another at their personal address. We will not ask you to explain why you are making the request. Requests must be made in writing to Business Office Manager.

4. You have the right to request changes to your health information. This means you may ask for changes to be made (amended) in PHI about you in a designated record set for as long as we keep this information. In certain cases, we may deny your request for a change. If we deny your request, you have the right to file a statement with the Business Office Manager, stating that you disagree. We may prepare a response to your statement and will provide you with a copy of this response. If you wish to change your PHI, please contact the Business Office Manager. Requests for changes must be in writing.

5. You have the right to receive a record of when your health information has been disclosed by the Facility. You have the right to request a record (accounting) of when the Facility has disclosed your PHI. This right applies to any time the Facility discloses your PHI for purposes other than treatment, payment, or health care operations as described in this Privacy Notice. We are not required to account for information releases: that you requested, that you agreed to by signing an Authorization Form, that are in our Nursing Home/Adult Care Home Directory, that are given to family or friends involved in your care, or certain other releases we are allowed to make without your permission. The request for a record must be made in writing to the Business Office Manager. The request should state the time period for the list. We are not required to provide a list for information released before April 14, 2003. Requests for records about The Facility's's disclosures of your PHI may not be made for time periods of more than six (6) years or it could be an earlier time period depending upon what the law requires.

6. You have the right to receive a paper copy of this Notice of Privacy Practices and will be offered one at the time you are admitted to the Nursing Home/Adult Care Home. You will need to acknowledge either receipt of the Notice of Privacy Practices or your refusal or need to receive a copy.

XVI. WHAT IF I HAVE A QUESTION OR COMPLAINT?

If you have questions regarding your privacy rights or you believe your privacy rights have been violated and wish to file a complaint, please call the Deseret Health Group's Compliance/Privacy Officer at (801) 296-5105. You may also report the issue by calling the anonymous reporting hotline at (877) 864-2046.

You may also contact the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. You can write to:

Regional Manager - OCR
U.S. Dept. Health and Human Services
601 East 12th Street - Room 24
Kansas City, MO 64106
Voice Phone (816) 426-7277
Fax (816) 426-3686
TDD (816) 426-7065