Notice of Privacy Practices for Protected Health Information
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.
During the course of providing services and care to you, we gather, create, and retain certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is characterized as your “protected health information.” This Notice of Privacy Practices describes how we maintain the confidentiality of your protected health information and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.
B. OUR RESPONSIBILITIES
We are required by federal and state law to maintain the privacy of your protected health information. We are also required by law to provide you with this Notice of Privacy Practices that describes our legal duties and privacy practices with respect to your protected health information. We will abide by the terms of this Notice of Privacy Practices. We reserve the right to change this or any future Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain, including protected health information already in our possession. If we change our Notice of Privacy Practices, we will personally deliver or mail a revised notice to you at your current address. In addition, the notice will be posted in a clear and prominent place in the facility and on our website (www.thematherevanston.com).
C. USE AND DISCLOSURE WITH YOUR AUTHORIZATION
We will require a written authorization from you before we use or disclose your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. An authorization is generally required for the following uses or disclosures, except in very limited circumstances: (1) uses or disclosures of psychotherapy notes; (2) uses or disclosures of protected health information for marketing purposes; and (3) disclosures of protected health information that constitute its sale. We have prepared an authorization form for you to use that authorizes us to use or disclose your protected health information for the purposes set forth in the form. The form is titled: Authorization for Use and Disclosure of Protected Health Information. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. We then will not use or disclose your protected health information, except where we have already relied on your authorization.
D. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION
We will use or disclose your protected health without your written authorization in the following circumstances:
1. Your Care and Treatment
We may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For example, we may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. We may also disclose your protected health information to individuals who will be involved in your care if you leave The Mather Evanston.
2. Billing and Payment
a. Medicare, Medicaid and Other Public or Private Health Insurers – We may use or disclose your protected health information to public or private health insurers (including medical insurance carriers, HMOs, Medicare, and Medicaid) in order to bill and receive payment for your treatment and services that you receive at The Mather Evanston. The information on or accompanying a bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
b. Health Care Providers – We may also disclose your protected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed.
3. Provision of Basic Information About Residents
We allow staff to provide certain basic information about a resident to persons who ask for the resident by name and to members of the clergy. Unless you notify us that you object, we will disclose your name, your location at The Mather Evanston, and your general condition to anyone who asks for you by name. We will disclose your name, your location at The Mather Evanston, your general condition, and your religious affiliation to members of the clergy.
4. Family Members and Close Personal Friends
Unless you specifically object, we may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person’s involvement with your care or directly relevant to payment related to your care. We may also disclose your protected health information to a family member, personal representative, or other person responsible for your care to assist in notifying them of your location, general condition, or death.
5. Disclosures Within The Mather Evanston/Directory
Unless you specifically object, we may disclose certain general information about you (e.g., past activities, present interests, birthday, and location if hospitalized) to persons within The Mather Evanston, including other residents and staff, by means such as newsletter or bulletin board. We may create a resident directory to be shared with staff and other residents.
6. Health Care Operations
We may use or disclose your protected health information for our health care operations at The Mather Evanston. These uses and disclosures are necessary to manage The Mather Evanston and to monitor our quality of services and care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff in caring for you.
7. Workforce Members
It is our policy to allow members of our workforce to share residents’ protected health information with one another to the extent necessary to permit them to perform their legitimate functions on our behalf. At the same time, we will work with and train our workforce members to prevent unnecessary or extraneous communications that violate the rights of our residents to have the confidentiality of their protected health information maintained.
8. Business Associates
We may contract with certain individuals or entities to provide services on our behalf. Examples include data processing, quality assurance, legal, or accounting services. We may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on our behalf. We will have a contract with our business associates that obligate the business associates to maintain the confidentiality of your protected health information.
9. Licensing, Certification, Accreditation, and Health Oversight
We may disclose your protected health information to any government or private agency, such as to the state licensing agency, federal Centers for Medicare and Medicaid Services (CMS), and CMS administrative contractors, responsible for licensing, certifying, or accrediting The Mather Evanston so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight. If we elect to pursue accreditation, we will enter into an agreement with the private agency that accredits health care providers requiring the agency to protect the confidentiality of your protected health information.
10. Abuse Reporting
We will disclose protected health information about a resident who is suspected to be the victim of elder abuse, neglect or domestic violence to the extent necessary to complete any oral or written report mandated by law. Under certain circumstances, we may disclose further protected health information about the resident to aid the investigating agency in performing its duties. We will promptly inform the resident about any disclosure unless we believe that informing the resident would place the resident in danger of serious harm, or would be informing the resident’s personal representative, whom we believe to be responsible for the abuse, and believes that informing such person would not be in the resident’s best interest.
11. Legal Process
We will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency. We will only disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, a grand jury, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made by the party issuing the subpoena to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.
12. Law Enforcement Agencies and Officials
We will disclose protected health information to law enforcement agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons. In addition, we may disclose such information as necessary to assist law enforcement officials investigating crimes involving residents.
13. National Security and Intelligence Activities
We will disclose protected health information about a resident to authorized federal officials conducting national security and intelligence activities or as needed to protect federal and foreign officials.
14. Public Health Activities
We may disclose your protected health information to any public health authority that is authorized by law to collect it for purposes of preventing or controlling disease, injury, or disability.
We may use your protected health information or disclose it to business associates in order to inform you about treatment alternatives or health-related benefits and services that may be of interest to you, to make face-to-face communications with you about a service or product, or to provide you with a promotional gift of nominal value. Otherwise, we will obtain a specific written authorization from you or your personal representative before using or disclosing protected health information for marketing purposes.
We may use certain protected health information to contact you in an effort to raise money for The Mather Evanston and its operations. We may disclose the protected health information to business associates or to related foundations that we use to raise funds for our own benefit. The information to be used or disclosed for these purposes will be limited to certain demographic information, the dates of treatment, the department where services were provided, the treating physician, outcome information, and health insurance status. Each fundraising communication will provide a means by which you can opt out of receiving further such communications.
17. Sale of Protected Health Information
We may disclose your protected health information for remuneration in certain very narrow circumstances such as where a governmental agency reimburses us for our expenses in providing information for public health purposes. Otherwise, we will obtain a specific written authorization from you or your personal representative before receiving reimbursement for using or disclosing protected health information.
18. Coroner, Medical Examiner, or Funeral Director
We may disclose protected health information to a coroner, medical examiner, or funeral director to allow them to carry out their duties.
19. Organ Procurement
If you are an organ donor, we may disclose your protected health information following your death to an organ procurement agency or tissue bank in order to aid in using your organs or tissues in transplantation.
20. Workers’ Compensation
We may disclose your protected health information in order to comply with workers’ compensation laws.
21. Preventing Danger to Identified Persons
We may disclose your protected health information to prevent an immediate, serious threat to the safety of an identified person.
22. Disaster Relief
We may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.
We may disclose your protected health information for research purposes, provided that an outside Institutional Review Board overseeing the research approves the disclosure of the information without a written authorization.
24. Peer Review, Utilization Review, and Quality Assurance
We may disclose your protected health information to health care providers for the purpose of conducting utilization review, peer review and quality assurance activities.
25. Other Disclosures Required or Permitted by Law
We will disclose protected health information about a resident when otherwise required or permitted by law.
E. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION
You have the following rights with respect to your protected health information. To exercise these rights, contact us at the following address: The Mather Evanston, 425 Davis St., Evanston, IL 60201; Attn: Executive Director.
1. Right To Request Access
You have the right to inspect and copy your health records maintained by us. This includes the right to have electronic records made available in electronic format to you or to someone whom you designate. In certain limited circumstances, we may deny your request as permitted by law. However, you may be given an opportunity to have such denial reviewed by an independent licensed health care professional.
2. Right To Request Amendment
You have the right to request an amendment to your health records maintained by us. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an opportunity to submit a written statement disagreeing with the denial.
3. Right To Request Special Privacy Protections
You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. You also have the right to request that we communicate protected health information to the recipient by alternative means or at alternative locations. And, at your request, we will not disclose your protected health information to a health plan or other insurer for payment or our health care operations where your information relates to a health care item or service for which you have paid us out of pocket in full. We are not required to agree to every request made by you for special privacy protections, but if we do, we will comply with your request, except in an emergency situation or until the restriction is terminated by you or us.
4. Right to an Accounting
You have the right to receive an accounting of disclosures of your protected health information created and maintained by us over the six years prior to the date of your request or for a lesser period. We are not required to provide an accounting of certain routine disclosures or of disclosures of which you are already aware. You also have the right to receive an accounting of electronic disclosures made up to three years from the date of your request where such disclosures were made for purposes of treatment, payment, or health care operations.
5. Right To Receive a Copy of the Notice of Privacy Practices
You have the right to request and receive a copy of our Notice of Privacy Practices for Protected Health Information in written or electronic form. If you have received this Notice of Privacy Practices in electronic form, you also have a right to receive a copy in written form upon request.
F. NOTICE OF SECURITY BREACHES
We will provide you with written notification (either by mail or email) in the event of a security breach involving your protected health information. The notification will describe what happened, the types of information involved, the steps that we are taking to deal with the situation, what you should do to protect yourself against any harmful consequences, and contacts for obtaining further information.
If you believe that your privacy rights have been violated, you may file a complaint with us at the following address: Attn.: Executive Director. Telephone: 1-847-492-4646 or Privacy Officer, Mather, 1603 Orrington Avenue, Suite 1800, Evanston, IL 60201. You also have the right to submit a complaint to the Office for Civil Rights, on behalf of the Secretary of the U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601, Attention: OCR Regional Manager, Telephone: (800) 368-1019, Fax: (312) 886-1807, TDD: (800) 537-7697. We will not retaliate against you if you file a complaint.
H. FURTHER INFORMATION
If you have questions about this Notice of Privacy Practices or would like further information about your privacy rights, contact us at the following address: The Mather Evanston, 425 Davis. Street, Evanston, IL 60201; Attn.: Executive Director.
The effective date of this HIPAA Notice of Privacy Practices is March 1, 2021.