St. Martin's in the Pines

NOTICE OF INFORMATION PRACTICES

"THIS 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."

A. Introduction:
As part of your health care, St. Martin's-in-the-Pines (the "Facility") originates and maintains numerous medical, billing, and other related records which contain information identifying you and describing your health history, symptoms, test results, diagnosis, treatment, and any plans for future care. This notice describes how this information may be used and disclosed by the Facility, as well as your rights and the Facility's duties with respect to such information.

B. Your Health Information Rights:
Although all records relating to the treatment you receive at the Facility are the property of the Facility, you have the following rights with respect to your health information:

the right to request restrictions on certain uses and disclosures of your health information as provided by 45 C.F.R. 164.522. The Facility is not required to agree to any requested restriction.
the right to obtain a copy of this Notice upon request.
the right to inspect and obtain a copy of your health information as provided in 45 C.F.R. 164.524.
the right to amend your health information as provided in 45 C.F.R. 164.526.
the right to obtain an accounting of disclosures of your health information as provided in 45 C.F.R. 164.528. A Request for Accounting of Disclosures of Health Information must be made on the Facility's form. Copies of these forms are available at the Facility.
the right to receive confidential communications of your health information as provided in 45 C.F.R. 164.522(b), as applicable.You may exercise any of these rights by contacting the Facility representative listed below.

C. Facility Responsibilities:
The Facility is required by law to maintain the privacy of your health information and to provide you with a notice as to the Facility's legal duties and privacy practices with respect to your health information. The Facility is also required to abide by the terms of this Notice, as it may be revised from time to time.
The Facility reserves the right to change the terms of this Notice and to make any revisions to the Notice effective for all your health information that the Facility maintains. Should the Facility change the terms of this Notice it will either hand-deliver or mail you a revised notice as well as post the revised notice in an area accessible to residents.

D. For More Information or to Report a Problem:
If you have questions or would like additional information, you may contact
Nancy Cobb, Apartments Administrator at (205) 314-4205
Tim Blanton, Assisted Living Administrator at (205) 314-4104
Jeff Burchfield, Nursing Home Administrator at (205) 314-4149
If you believe your privacy rights have been violated, you can file a complaint with
Mike Faulkner, Privacy Officer at 4941 Montevallo Road, Birmingham, AL 35210
or with the Secretary of the Department of Health and Human Services without fear of retaliation for filing a complaint. All complaints must be in writing. Secretary of Health and Human Services - Office for Civil Rights, US Dept. of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201

E. Use and Disclosure of Your Health Information.
The Facility is permitted to use or disclose your health information in the following ways:
Treatment: The Facility will use your health information in the provision and coordination of
your healthcare. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, and other health care providers who have a legitimate need for such information in your care and continued treatment. The Facility may share information about you with other providers in order to coordinate specific services, such as prescriptions, lab work and x-rays. The Facility also may disclose your health information to people outside the Facility who may be involved in your medical care after you leave the Facility, such as family members, clergy, and others used to provide services that are part of your care.
Family/Friends: The Facility may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the Facility.

Payment: The Facility may release health information about you for the purposes of determining coverage, billing, claims management, medical data processing, and reimbursement. Your health information may be released to an insurance company, third party payer or other entity (or their authorized representatives) involved in the payment of your medical bill and may include copies or excerpts of your medical record which are necessary for payment of your account. For example, a bill sent to a third party payer may include information that identifies you, your diagnosis, and the services and supplies provided to you.

Routine Healthcare Operations: The Facility may use and disclose your health information
during routine healthcare operations, including, but not limited to, quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities of the Facility.

Facility Directory: Unless you notify us that you object, the Facility will use your name and location in the Facility for directory purposes. This information may be provided to people who ask for you by name.

Business Associates: The Facility may disclose certain health information about you to business associates. A business associate is an individual or entity under contract with the Facility to perform or assist the Facility in a function or activity which necessitates the use or disclosure of health information. Examples of business associates, include, but are not limited to, consultants, accountants, lawyers, medical transcriptionist and third-party billing companies. The Facility requires the business associate to protect the confidentiality of your health information.

Marketing: The Facility may disclose certain contact information to a third party to provide marketing materials and information to you.

Regulatory Agencies: The Facility may disclose your health information to a health oversight agency for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary for the government and other health oversight agencies to monitor the healthcare system, government programs, and compliance with civil rights.

Law Enforcement/Litigation: The Facility may disclose your health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

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

Victims of Abuse: The Facility may disclose your health information to government authorities, such as social services authorities or protective agencies, if the Facility reasonably believes that you are a victim of abuse, neglect, or domestic violence.

Workers Compensation: The Facility may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Required by Law: The Facility will disclose medical information about you when required to do so by law.

Coroners, Medical Examiners, Funeral Directors: The Facility may release your health information to a coroner or medical examiner. This may be necessary, for example, to determine a cause of death. The Facility may also release your health information to funeral directors as necessary to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, the Facility 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.

Research: The Facility may disclose your health information to researchers when their research has been approved by an institutional review board that has reviewed the research purpose and established protocols to ensure the privacy of your health information. Before disclosing any of your health information we will verify that the researchers have obtained your consent to participate in the study.

Appointment Reminders/Treatment Alternatives: The Facility 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.

Food and Drug Administration (FDA): The Facility may disclose to the FDA health information relative to adverse events with respect to food supplements, products, and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.

Avert Threat to Health or Safety: The Facility may disclose your health information if the Facility in good faith believes that disclosure is necessary to prevent serious harm to an individual or the public.

Government Functions: When appropriate, the Facility may disclose health information to serve certain governmental functions. The entities who may receive this information include, but are not limited to the military, intelligence agencies, and correctional institutions.

Fundraising: The Facility may contact you as part of our fundraising efforts.

Other Uses: Any other uses or disclosures of your health information will be made only with your written authorization. You may revoke an authorization, in writing, at any time except to the extent that the Facility has relied on your authorization.

F. Effective Date:
The effective date of this notice is April 14, 2003.