Notice of Privacy Practices

The Franciscan Sisters of Chicago Service Corporation has always placed a high value on respecting the privacy of residents and their health information. The federal government has created a set of regulations to protect this right as well. This notice describes how health information about you may be used, disclosed and how you can get access to this information. It tells you about your rights and our responsibilities to protect the privacy of your health information. It also tells you what to do if you believe that we have violated any of your rights or any of our responsibilities. Please review the information in this notice carefully.

Reasonable efforts will be made to provide you with a personal copy of this notice and to obtain your acknowledgement thereof. We must follow the terms of this notice that are currently in effect. This notice will be given to you on the date that you first receive medical products, treatment or services from our Community.

We will notify you if we change this notice. If this notice is revised, a copy of the revised notice will be available upon request, posted at our Community and on our Web site. Changes to our practices may apply to health information we already have about you as well as any new information.

How We Use or Disclose Your Personal Health Information

We are required by law to maintain the privacy of your Personal Health Information. However, a resident’s information may be communicated via telephone or faxed as needed to facilitate treatment/services, payment/insurance verifications and other operational issues. In these situations, reasonable efforts will be made to safeguard the exchange to avoid inappropriate disclosures. In addition, we may use or disclose your health information in the following ways:

For Treatment

We will use Personal Health Information about you to provide you with treatment and services. We may share this information with members of our healthcare staff or with others involved in your care such as doctors, nurses, or other healthcare providers.

For Payment

We may use or disclose your Personal Health Information to bill and collect payment for the services we provide to you. We may contact your insurance plan or third-party payer to confirm your coverage or to request prior approval for a planned treatment or service.

Health Care Operations

We may use or disclose your Personal Health Information for operational purposes. For example, we may use your medical information to evaluate our services, including the performance of our staff in caring for you. We may also use this information to learn how to continually improve the quality and effectiveness of the health care services that we provide to you.

Common Disclosures for Treatment, Payment or Health Care Operations

Your name and address may be used to send you resident/patient satisfaction surveys.

We may contact you by telephone or by mail to remind you of a healthcare appointment or to discuss payment or treatment issues. If you are not home when we telephone you, we may leave messages for you. If you want us to contact you in a certain way or at a certain location, see “Right to Request Restrictions” in this notice.

There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we have a written contract with them that requires that they protect the privacy of your Personal Health Information.

Other Uses and Disclosures of Your Personal Health Information

Fund-raising

Your name and address and the dates you received treatment or services may be added to a mailing of patients in order to invite you to a fund-raising event or to send you a newsletter. If you do not want to receive these communications, please notify our Privacy Officer in writing.

Treatment Alternatives

We may use and disclose Personal Health Information about you to tell you about other health care treatments or services available to you. If you do not want to receive these communications, please notify our Privacy Officer in writing.

Health Related Benefits and Services

We may use and disclose Personal Health Information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may also use or disclose medical information about you to notify those persons of your location and general condition. If there is a family member, other relative or close friend to whom you do not want us to disclose medical information about you, please notify our Privacy Officer in writing.

Uses or Disclosures That Are Required or Permitted by Law

Disaster Relief

We may use or disclose Personal Health Information about you to assist in disaster relief efforts.

Required by Law

We may use or disclose Personal Health Information about you when the law requires us to do so.

Public Health Activities

We may disclose Personal Health Information about you for public health activities to prevent or control disease.

Victims of Abuse, Neglect or Domestic Violence

We may disclose Personal Health Information about you to a government agency if we believe you are the victim of abuse, neglect or domestic violence.

Health Oversight Activities

We may disclose Personal Health Information about you to a health oversight agency, such as licensing, regulatory or accreditation agency.

Legal Activities

We may disclose Personal Health Information about you in response to a court proceeding, in response to a subpoena or other legal process. We may also disclose Personal Health Information about you to authorized federal or state officials when a law or regulation requires us to do so.

Funeral Directors, Coroners and Medical Examiners

We may disclose Personal Health Information about you to these individuals as needed.

Organ Donation

We may disclose Personal Health Information about you to organ procurement organizations if you are an organ donor.

Military

If you are a member or veteran of the Armed Forces, we may use and disclose Personal Health Information about you to your military command.

Uses or Disclosures That Require Your Authorization

Uses and disclosures other than those discussed in this Notice will be made only with your written authorization. You may cancel your authorization at any time by notifying our Privacy Officer in writing.

If you cancel an authorization it will not have any affect on information that we have already disclosed. Some examples of uses or disclosures that may require your written authorization are:

A request to provide certain Personal Health Information to a drug company for marketing purposes.

A request to provide your Personal Health Information to your Attorney for use in a lawsuit.

Your Rights in regards to your Personal Health Information

The health or medical record created about you is the physical property of the Community. The information in the health or medical record belongs to you. As such, you have the following rights:

Right to Request Restrictions

You have the right to ask us not to use or disclose your Personal Health Information for a particular reason related to treatment, payment or our operations. This request must be made in writing to our Privacy Officer. We do not have to agree to your request for reasons such as the limiting effect it has on our ability to provide treatment, services or obtain payment. If we agree to your request, we must keep the agreement, except in the case of a medical emergency. Either you or the Community can stop a restriction at any time.

Right to Inspect and Copy Your Medical Information

You have the right to ask to inspect and obtain a copy of your medical record. You must submit your request in writing to the Community. We may charge a fee for the costs of copying and/or mailing your medical record for you.

We may deny your request under certain limited circumstances. If your request is denied, you will be notified in writing and will be informed of your rights relating to requesting a review of our denial.

Right to Request Amendments to Your Medical Information

You have the right to request that we correct or amend your medical record. If you believe that any medical information in your record is incorrect or that important information is missing, you must submit your request in writing to the Medical Records Department. We have the discretion of accepting or denying your request. If your request is denied, you will be notified in writing and will be informed of your rights relating to requesting a review of our denial.

Right To An Accounting of Disclosures of Health Information

You have the right to find out what disclosures of your medical information have been made by contacting the community’s Medical Records Department. The list of disclosures is called an accounting. The accounting may be for up to six (6) years prior to the date on which you request the accounting, but cannot include disclosures made before April 14, 2003. The accounting will not include disclosures for treatment, payment or healthcare operations or certain other exceptions.

Requests for an accounting of disclosures must be submitted in writing to our Privacy Officer. You are entitled to one free accounting in any twelve (12) month period. We may charge you for the cost of providing additional accountings. You will be notified in advance of any charges.

Right to Obtain a Copy of the Notice

You have the right to ask for and receive a hard copy of this notice and any revisions made to the notice at any time. In addition, the revised notice will be posted in a prominent location in our Community and on our Web site on or after the effective date of the revision.

How to Make a Complaint

Please notify us if you believe we have violated your privacy rights. In addition, you have the right to make a complaint to the United States Secretary of Health and Human Services. There is no risk involved if you file a complaint with us or the Secretary of Health and Human Services.

To file a complaint with us, contact by phone or by mail:

David J Pagano, RN

Vice President of Clinical Services

Franciscan Ministries

11500 Theresa Drive

Lemont, IL 60439

1-877-435-7372

DPagano@franciscanministries.org

Complaints to the Community or Secretary must: (1) be filed in writing, either on paper or electronically; (2) name the community that is the subject of the complaint and describes the acts or omissions believed to be in violation; and (3) be filed within 180 days of when you knew or should have known that the act or omission complained of occurred. This time limit may be waived for good cause shown. Complaints to the Secretary of Health and Human Services may be filed only with respect to alleged violations occurring on or after April 14, 2003.

The Secretary of Health and Human Services has delegated to the Office of Civil Rights (OCR) the authority to receive and investigate complaints as they may relate to a violation of this federal regulation. Complaints should be addressed to the OCR Regional Office that is assigned to the respective state in which the Community is located. See Attachment A for a complete listing. Complaints may also be filed via e-mail at OCRComplaint@hhs.gov. Individuals may, but are not required to, use OCR’s Health Information Privacy Complaint Form. To obtain a copy of this form, or for more information about the Privacy Rule or how to file a complaint with OCR, contact any OCR office or go to www.hhs.gov/ocr/hipaa/.

Questions and Information

If you have any questions or want more information about this Notice of Privacy Practices, please contact:

David J Pagano, RN

Vice President of Clinical Services

Franciscan Ministries

11500 Theresa Drive

Lemont, IL 60439

1-877-435-7372

DPagano@franciscanministries.org

Where to File Complaints Concerning Health Information Privacy

For complaints involving communities located in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, or Vermont:

Region I Office of Civil Rights, U.S. Department of Health & Human Services

Government Center, J.F. Kennedy Federal Building – Room 1875

Boston, Massachusetts 02203

Voice Phone (617) 565-1340

FAX (617) 565-3809 TDD (617) 565-1343

For complaints involving covered entities located in New Jersey, New York, Puerto Rico, or Virgin Islands:

Region II Office of Civil Rights, U.S. Department of Health & Human Services

Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312

New York, New York, 10278

Voice Phone (212) 264-3313

FAX (212) 264-3039 TDD (212) 264-2355

For complaints involving covered entities located in Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, or West Virginia:

Region III Office of Civil Rights, U.S. Department of Health & Human Services

150 S. Independence Mall West, Suite 372, Public Ledger Building

Philadelphia, PA 19106-9111

Main Line (215) 861-4441 Hotline (800) 368-1019

FAX (215) 861-4431 TDD (219) 861-4440

For complaints involving covered entities located in Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, or Tennessee:

Region IV Office of Civil Rights, U.S. Department of Health & Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, SW.

Atlanta, Georgia 30303-8909

Voice Phone (404) 562-7886

FAX (404) 562-7881 TDD (404) 331-2867

For complaints involving covered entities located in Illinois, Indiana, Michigan, Minnesota, Ohio or Wisconsin:

Region V Office of Civil Rights, U.S. Department of Health & Human Services

233 N. Michigan Avenue, Suite 240, Chicago, IL 60601

Voice Phone (312) 886-2359

FAX (312) 886-1807 TDD (312) 353-5693

For complaints involving covered entities located in Arkansas, Louisiana, New Mexico, Oklahoma, or Texas:

Region VI Office of Civil Rights, U.S. Department of Health & Human Services

1301 Young Street, Suite 1169, Dallas, TX 75202

Voice Phone (214) 767-4056

FAX (214) 767-0432 TDD (214) 767-8940

For complaints involving covered entities located in Iowa, Kansas, Missouri, or Nebraska:

Region VII Office of Civil Rights, U.S. Department of Health & Human Services

601 East 12th Street – Room 248, Kansas City, Missouri 64106.

Voice Phone (816) 426-7278

FAX (816) 426-3686 TDD (816) 426-7065

For complaints involving covered entities located in Colorado, Montana, North Dakota, South Dakota, Utah, or Wyoming:

Region VIII Office of Civil Rights, U.S. Department of Health & Human Services

1961 Stout Street – Room 1185 FOB, Denver, CO 80294-3538

Voice Phone (303) 844-2024

FAX (303) 844-2025 TDD (303) 844-3439

For complaints involving covered entities located in American Samoa, Arizona, California, Guam, Hawaii, or Nevada:

Region IX Office of Civil Rights, U.S. Department of Health & Human Services

50 United Nations Plaza – Room 322, San Francisco, CA 94102

Voice Phone (415) 437-8310

FAX (415) 437-8329 TDD (415) 437-8311

For complaints involving covered entities located in Alaska, Idaho, Oregon, or Washington:

Region X Office of Civil Rights, U.S. Department of Health & Human Services

201 Sixth Avenue, Suite 900, Seattle, Washington 98121-1831

Voice Phone (206) 615-2287

FAX (206) 615-2297 TDD (206) 615-2296