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Notice of Privacy Practices

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Overcomers Notice of Privacy Practices

YOU (the person receiving care and services) MAY BE USED AND
We respect the privacy of your personal health information and are committed to
maintaining our Patient’s and Resident’s confidentiality. This Notice applies to all
information and records related to your care that our facility has received or
created. It extends to information received or created by our employees, staff,
consultants, volunteers and physicians. This Notice informs you about the possible
uses and disclosures of your personal health information. It also describes your
rights and our obligations regarding your personal health information.
We are required by law to:
Maintain the privacy of your protected health information;
Provide to you this Notice of our legal duties and privacy practices relating
to your personal health information;
notify you in the event of a breach involving your unsecured health
information; and
Abide by the terms of the Notice that are currently in effect.
Except as may be otherwise required by law, our obligations and your rights under
this Notice terminate after fifty (50) years after your death.
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Affiliated Covered Entities: This privacy notice applies to Isabella Geriatric
Center, Inc. and Isabella Visiting Care, Inc. and Isabella Care at Home, Inc. who
have designated themselves as affiliated covered entities Affiliated covered
entities are considered as one covered entity for HIPAA privacy purposes.
Affiliated covered entities may share information amongst themselves as permitted
by law, including for purposes of treatment, payment and health care operations.
You will be asked to sign a receipt indicating you have received this notice.
This notice informs you about our practices, policies and requirements related
to the use and disclosure of your personal health information for purposes of
treatment, payment and health care operations. We have described these uses
and disclosures below and provide examples of the types of uses and
disclosures we may make in each of these categories.
For Treatment. We will use and disclose your personal health information in
providing you with treatment and services. We may use or disclose your
personal health information to facility and non-facility personnel who may be
involved in your care, such as physicians, nurses, nurse aides, and physical
therapists. For example: a nurse caring for you will report any change in your
condition to your physician. We also may disclose personal health information
to individuals who will be involved in your care when or after you leave the
facility. For example: we may disclose personal health information to a
hospital when you are transferred to the hospital.
For Payment. We may use and disclose your personal health information so
that we can bill and receive payment for the treatment and services you receive
at the facility. For billing and payment purposes, we may disclose your personal
health information to your representative, and insurance or managed care
company, Medicare, Medicaid or another third party payor. For example, we
may contact Medicare or your health plan to confirm your coverage or to
request prior approval for a proposed treatment or service.
For Health Care Operations. We may use and disclose your personal health
information for facility operations. These uses and disclosures are necessary to
manage the facility and to monitor our quality of care. For example, we may
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use personal health information to evaluate our facility’s services, including the
performance of our staff.
Facility Directory. Unless you object, we will include certain limited
information about you in our facility directory. This information may include
your name, your location in the facility, and your general condition and your
religious affiliation. Our directory does not include specific medical
information about you. We may disclose information in our directory, except
for your religious affiliation, to people who ask for you by name. For example,
we may provide a visitor with your room number. We may provide the
directory information including your religious affiliation, to any member of the
Individuals Involved in Your Care or Payment for Your Care. Unless you
object, we may disclose your personal health information to a family member or
close personal friend, including clergy, who is involved in your care.
Following your death: We may disclose your personal health information after
your death to a family member, other relative, close friend or any other person
previously identified by you who were involved with your care or payment for
your care prior to your death to the extent such disclosure is relevant to such
person’s involvement with your care or payment for your care, unless doing so
in inconsistent with any prior expressed preferences of yours that is known to
Disaster Relief. We may disclose your personal health information to an
organization assisting in a disaster relief effort.
As Required By Law. We will disclose your personal health information when
required by law to do so.
Public Health Activities. We may disclose your personal health information for
public health activities. These activities may include, for example.
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Reporting to a public health or other government authority for preventing
or controlling disease, injury or disability, or reporting child abuse or
Reporting to the federal Food and Drug Administration (FDA)
concerning adverse events or problems with products for tracking
products in certain circumstances, to enable product recalls or to comply
with other FDA requirements;
To notify a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or spreading a disease
or condition or
For certain purposes involving workplace illness or injuries.
Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe
that you have been a victim of abuse, neglect or domestic violence, we may
use and disclose your personal health information to notify a government
authority if required or authorized by law, or if you agree to the report.
Health Oversight Activities. We may disclose your personal health
information to a health oversight agency for oversight activities authorized
by law. These may include, for example, audits, investigations, inspections
and licensure actions or other legal proceedings. These activities are
necessary for government payment or regulatory compliance, and
compliance with civil rights laws.
Judicial and Administrative Proceedings. We may disclose your personal
health information in response to a court or administrative order. We also
may disclose information in response to a subpoena, discovery request, or
other lawful process, provided we receive certain satisfactory assurances
from the party seeking the information or we make reasonable; efforts to
contact you about the request or to obtain an order of agreement protecting
the information.
Law Enforcement. We may disclose your personal health information for
certain law enforcement purposes, including
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As required by law to comply with reporting requirements;
To comply with a court order or court ordered warrant, grand jury
subpoena, administrative subpoena or summons, investigative
demand or similar legal process;
To identify or locate a suspect, fugitive, material witness, or missing
When information is requested about the victim of a crime if the
individual agrees or under other limited circumstances;
To report the information about a suspicious death;
To provide information about criminal conduct occurring at the
To report information in emergency circumstances about a crime; or
Where necessary to identify or apprehend an individual in relation to
a violent crime or an escape from lawful custody.
Research. We may allow personal health information of residents from our
facility to be used or disclosed for research purposes provided that the
researcher adheres to certain privacy protections. Your personal health
information may be used for research purposes only if the privacy aspects of
the research have been reviewed and approved by a special Privacy Board
(comprised of select Board of Director members and others as appropriate)
or Institutional Review Board, if the researcher is collecting information in
preparing a research proposal, if the research occurs after your death, or if
you authorize the use or disclosure.
Coroners, Medical Examiners, Funeral Directors, Organ Procurement
Organizations. We may release your personal health information to a
coroner, medical examiner, funeral director or, if you are an organ donor, to
an organization involved in the donation of organs and tissue.
To Avert a Serious Threat to Health or Safety. We may use and disclose
your personal health information when necessary to prevent a serious threat
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to your health or safety or safety of the public or another person. However,
any disclosure would be made only to someone able to help prevent the
Military and Veterans. If you are a member of the armed forces, we may
use and disclose your personal health information as required by military
command authorities. We may also use and disclose personal health
information about foreign military personnel as required by the appropriate
foreign military authority.
Workers’ Compensation. We may use or disclose your personal health
information to comply with laws relating to workers’ compensation or
similar programs.
National Security and Intelligence Activities: Protective Services for the
President and Others. We may disclose personal health information to
authorized federal officials conducting national security and intelligence
activities or as needed to provide protection to the President of the United
States, certain other persons or foreign heads of states or to conduct certain
special investigations.
Fundraising Activities. We may use certain personal health information to
contact you or your designated representative in an effort to raise money for
the facility and its operations. We may disclose personal health information
to a foundation related to the facility or professional fundraiser so that the
foundation or professional fundraiser may contact you in raising money for
the facility. In doing so, we would only release the following information:
demographic information, including, your name, address, contact
information, age; gender; and date of birth; the dates you received treatment
or services at the facility; department of service information; and outcome
information. Any written fundraising material sent by us or on our behalf
by a professional fundraiser or related foundation will contain, in a clear and
conspicuous manner, a provision indicating how you can elect not to receive
any further fundraising communications. We may not condition your
treatment on your choice with respect to the receipt of fundraising
Appointment Reminders. We may use or disclose personal health
information to remind you about appointments.
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Treatment Alternatives. We may use or disclose personal health
information to inform you about treatment alternatives that may be of
interest to you.
Health-Related Benefits and Services. We may use or disclose personal
health information to inform you about health-related benefits and services
that may be of interest to you.
We must obtain your written authorization for the use and disclosure of (a)
psychotherapy notes (except to carry out the following limited treatment,
payment an health care operations: use by the originator of the notes; use by
us for our own mental health training purposes or to defend ourselves in a
lawsuit or other type of proceeding brought by you or on your behalf by
your personal representative (b) , marketing (except as set forth below) and
(c) the sale of protected health information (see below).
You may revoke your authorization to use or disclose personal health
information in writing, at any time. If you revoke your authorization, we
will no longer use or disclose your personal health information for the
purposes covered by the authorization, except where we have already relied
on the authorization.
You have the following rights regarding your personal health information
at the facility:
Right to Request Restrictions. You have the right to request a restriction or
limitation on the health information we use or disclose about you for
treatment, payment, or health care operations. You also have the right to
request a limit on the health information we disclose about you to someone,
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such as a family member or friend, who is involved in your care or in the
payment of your care or for notification purposes. For example, you could
ask that we not use or disclose information regarding a particular treatment
that you received.
We are not required to agree to your requested restriction, except that
we are required to comply with the requested restriction if the
disclosure is to a health plan for purposes of carrying out payment and
health care operations and is not otherwise required by law, and the
personal health information pertains solely to a health care item or
service for which we have paid in full by you or by someone, other than
the health plan, on your behalf.If we agree to your requested
restriction, we will comply with your request unless: (i) the release of
the information is needed to provide you emergency treatment and,
where such emergency treatment is provided by a health care provider
other than us, we will request such other provider not to further use or
disclose the information; or (ii) the release of the information is
required or otherwise permitted by law.
If you request a restriction, we will need to know the following: (a) what
information you want to restrict; (b) whether you want the restriction to
apply to our use, to disclosures or both; and (c) whether the restriction will
apply to all disclosures or will be limited to certain disclosures (for example,
disclosures to a family member).
We may terminate this agreement with regard to a restriction on the use or
disclosures of protected health information. We may terminate this
agreement with regard to restrictions if (a) you agree to or request the
termination in writing, or (b) you orally agree to the termination and the oral
agreement is documented or (c) we inform you that we are terminating the
agreement, except that we cannot terminate our agreement to a restriction
pertaining to disclosures of your health information to a health plan as
described above. and that such termination is only effective with respect to
protected health information created or received after we inform you.
Right of Access to Personal Health Information. You have the right to
inspect and/or obtain a copy of your health information that we maintain in a
designated record set... Generally, this includes medical and billing records,
but does not include psychotherapy notes, information compiled in
reasonable anticipation of or for use in a criminal, civil or administrative
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action or proceeding or if prohibited by law under the clinical laboratory
improvement amendments of 1988. We will provide you with access to
your health information in the form and format requested, provided that it is
readily producible in such form or format or, if not, in a readable hard copy
or such other form and format as agreed to by you and us (see below with
respect to electronic records maintained by us).
To the extent that we maintain your personal health information
electronically and you request an electronic copy of your health
information, we will provide you with access in the electronic form and
format requested, provided that it is readily producible in such form or,
if not. in a readable electronic form and format that is agreeable to both
you and us.
If your request for access directs us to transmit a copy, including an
electronic copy, of your health information directly to another
individual designated by you, we will provide the copy to the individual
designated by you. Your request to transmit a copy of your health
information to another individual must be in writing, must be signed by
you or your personal representative and must clearly identify the
designated individual.
We may deny your request to inspect and copy your health information in
certain limited circumstances. If you are denied access to your health
information, except in circumstances where the denial is non-reviewable,
you may request that the denial be reviewed. Another licensed health care
professional selected by our facility will review your request and the denial.
The person conducting the review will not be the person who initially denied
your request. We will comply with the outcome of this review.
If you request a copy of your information, we may charge a fee for the costs
of copying, mailing, if applicable, or other supplies associated with your
Right to Request Amendment. You have the right to request the facility
to amend any personal health information maintained by the facility for
as long as the information is kept by or for the facility. The request for
the amendment of personal health information must be in writing and must
set for the reason for the request. Isabella will provide a form for this purpose
upon request.
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We may deny your request for amendment if the information
Was not created by the facility, unless the originator of the
information is no longer available to act on our request;
Is not part of the personal health information maintained by or for the
Is not part of the information to which you have a right of access; or
Is already accurate and complete, as determined by the facility.
If we deny your request for amendment, we will give you a written denial
including the reasons for the denial and the right to submit a written
statement disagreeing with the denial.
Right to an Accounting of Disclosures. You have the right to request an
“accounting” of our disclosures of your personal health information. This is
a listing of certain disclosures of your personal health information made by
the facility or by others on our behalf, but does not include disclosures for
treatment, payment and health care operations or certain other exceptions.
Isabella will provide to you, upon request, a form requesting such an
accounting. This request will include a time period, which may not be prior
to April 13, 2003, and not for a period beyond six years. An accounting will
include, if requested: the disclosure date; the name of the person or entity
that received the information and address, if known; a brief description of
the information disclosed; a brief statement of the purpose of the disclosure
or a copy of the authorization or request; or certain summary information
concerning multiple similar disclosures. The first accounting provided
within a 12-month period will be free; for further requests, we may charge
you our costs.
Right to a Paper Copy of This Notice. You have the right to obtain a paper
copy of this Notice, even if you have agreed to receive this Notice
electronically. You may request a copy of this Notice at any time. You may
obtain a copy of this Notice at our website
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Right to Request Confidential Communications. You have the right to
request that we communicate with you concerning personal health matters in
a certain manner or at a certain location. For example, you can request that
we contact you only at a certain phone number. We will accommodate your
reasonable requests.
Marketing. Marketing is a communication about a product or service that
encourages the recipient of the communication to purchase or use the
product or service. Except where we receive, directly or indirectly, financial
remuneration in exchange for making one of the following communications,
marketing does not include the following treatment and health care operation
(i) for your treatment, including case management or care
coordination, or to direct or recommend alternative treatments,
therapies, health care providers or health care settings;
(ii) to describe a health care product or service or the payment for
such product or service that is provided by us; or
(iii) for case management and care coordination, contacting you or
your personal representative about treatment alternatives and
related functions to the extent such communications are not
considered treatment.
We must obtain your written authorization in order to use or disclose your
health information to make a marketing communication (including those
communications set forth at subsections (i), (ii) and (iii) above when we
receive financial remuneration, directly or indirectly, in exchange for
making such communication), except where the communication is in the
form of:
(i) a face-to-face communication made by us to you or your
personal representative; or
(ii) a promotional gift of a nominal value provided by us.
Sale of Health Information: We cannot sell your health information, except
pursuant to your written authorization. Certain disclosures are not
considered the sale of health information, including but not limited to the
(i) for permitted public health purposes;
(ii) for permitted research purposes;
(iii) for treatment and payment purposes;
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(iv) for permitted due diligence involving the sale, transfer, merger
or consolidation of all or part of our business;
(v) for disclosures to you; or
(vi) for disclosures required by law.
In the event we discover or we are notified by one of our business associates
that there has been a breach involving your personal health information, we
will notify you of the breach without unreasonable delay but in no event
later than sixty (60) calendar days after the breach has been discovered,
except if we are notified by a law enforcement official that such notification
would impede a criminal investigation or cause damage to national security.
Unless otherwise required by law, we will notify you in writing by first class
mail addressed to your last known address or by electronic mail if you have
previously notified us in writing that this is your preferred method of
notification. No notice will be provided if the breach involves person health
information which is in a secured format.

Yes. I have reviewed the above Privacy notice and understand its contents.