Notice of
Privacy Practices

Effective 4/14/03

What is the Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMAITON. PLEASE REVIEW IT CAREFULLY.

Please review this notice carefully. If you have any questions, please contact the Privacy Officer at 618-651-3205.

Who will follow this notice

We are committed to protecting your medical information.

As a resident of Faith Countryside Homes, information about your care and treatment is compiled into a medical record. This record is needed to provide quality care and comply with certain legal requirements.

This notice applies to all records of care you receive through Faith Countryside Homes, Highland, including information generated by the staff and your physician. Those individuals who may have access to your medical records may include, but not be limited to:

" Any healthcare professional authorized to enter information into your medical record;
" Employees from all areas of Faith Countryside Homes;
" Any member of a volunteer group we allow to help you while you are residing at Faith Countryside Homes;
" Any business associate or partner with whom we may share information for the purpose of treatment, payment or health care operations.

Your rights regarding your medical information

Right to inspect and copy

You or your responsible party have the right to review (with 24 hours notice) and/or request a copy of the medical information (with 48 hours notice) that may have been used to make decisions about your care. These requests must be in writing. A fee may be charged for copying, mailing or other expenses associated with your request.

Right to amend

If you feel that your medical record is incorrect or incomplete, you may request, in writing, an amendment, as long as the information is kept by Faith Countryside Homes.

Your request to amend the record may be denied for the following reasons:
" Was not made in writing
" Does not include why the information should be changed
" Includes information not created by Faith Countryside Homes unless the person or entity that did create the information is no longer available
" Is not part of the medical record kept by Faith Countryside Homes
" We believe the information is accurate as it stands

Right to an accounting of disclosures

You have the right to a list of when we disclosed your medical information, other than for treatment, obtaining payment, improving healthcare operations or where you authorized a disclosure.

This request must be in writing and include the time period desired, which must be less than a six-year period beginning after April 14, 2003. You may receive a copied list of disclosures. Other requests will be charged according to the cost of producing the list; we will inform you of the cost before completing the list.

Right to request restrictions

You have the right to request, in writing a restriction or limitation on the medical information about you for treatment, payment or health care operations shared with persons involved in your care, except when specifically authorized, when required by law, or in an emergency. We are not legally required to agree to your request.

Right to Request Confidential Communications

You have the right to request that your medical information be communicated to you in a confidential manner. This request must be in writing and include how or where you wish to be contacted.

Changes to this Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at Faith Countryside Homes. The notice will contain on the first page the effective date. You will be asked to acknowledge in writing your receipt of this notice if you have not already done so.

Your health care provider may have different policies regarding his/her use and disclosure of your medical record created in his/her office or clinic. Please contact your health care provider.

Legal requirements

The law requires us to:
" Ensure that any information that can lead to your identification be kept private;
" Notify you of our legal duties and privacy practices with respect to your medical information; and
" Follow the terms of the notice currently in effect.

How we may use/disclose your medical information

The following categories describe different ways we use/disclose medical information. Not every use or disclosure in a category will be listed, however, all of the ways we are permitted to use/disclose information will fall within one of the categories:

We may use/disclose your medical information for
" Treatment, such as by sending information to a specialist as part of a referral;
" Obtaining payment, such as by sending billing information to yourself, insurance company or responsible party; and
" Supporting our healthcare operations, such as by comparing resident data to improve treatment methods.

We may contact you to remind you of an appointment, to inform you of other treatment alternatives, health-related benefits or services; or for fundraising efforts.

When you are admitted to Faith Countryside Homes, a general information sheet will be compiled containing your name, birthday, room location, veteran's status and religious affiliation. Your name will be posted outside your door. Our monthly newsletter often contains information or photos about our residents, unless requested differently. Information, excluding religious affiliation, will not be released unless someone asks about you by name. Your religious affiliation may be disclosed only to a clergy member, even if they do not ask for you by name.

We may also disclose information to a friend or family member who is involved in your medical care or to disaster relief authorities so your family can be notified of your location and condition.

In situations not covered by this notice, we will ask for your written authorization before using/disclosing your medical information. If you authorize this use/disclosure, you can revoke that authorization by a written notice.

Subject to certain requirements, we may use/disclose your medical information to the following agencies and for the following reasons without your authorization:
" Public health purposes
" Law enforcement
" Coroners and/or medical examiners
" National security
" Abuse and neglect reporting
" Health oversight audits and inspections
" Funeral arrangements
" Worker's compensation purposes
" Emergencies
" When required by federal, state or local law such as a request from law enforcement in specific circumstances or in response to valid judicial or administrative orders.

Complaints

If you are concerned that your privacy may have been violated or you disagree with a decision we made about access to your records, you may contact the Privacy Officer at 618-651-3205.

All verbal complaints must be followed by a written description; all written complaints should be addressed to:

HIPAA Privacy Officer
Faith Countryside Homes
100 Faith Drive
Highland, IL 62249

All complaints will be investigated by the Privacy Officer, and, when necessary, the HIPAA Privacy Committee. Each complaint will be answered.

Written complaints may also be addressed to the United States Department of Health and Human Services, Office of Civil Rights. The current address is available from the Privacy Officer.

Under no circumstances will you be penalized or retaliated against for filing a complaint.

Effective April 14, 2003, this document outlines the uses and disclosures of protected health information required by the Health Insurance Portability and Accountability (HIPAA) Act passed in 1996 under Section 164.520.