NOTICE OF PRIVACY PRACTICES

(45 CFR §164.520(a)) 

Consumer Name: ____________________________________ Effective Date: __________

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.

If you have any questions about this notice, please contact the Privacy Officer.

WHO WILL FOLLOW THIS NOTICE.

This notice describes our practices and that of:

  • Any health care professional authorized to enter information into your chart.
  • All departments and units of Forte Residential, Inc.,.
  • Any member of a volunteer group we allow to help you at Forte Residential, Inc.,.
  • All employees, staff and other personnel of Forte Residential, Inc.,.
  • All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or Forte Residential, Inc., operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Forte Residential, Inc.,. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Forte Residential, Inc.,. Other Health Care Rehabilitation Facilities may have different policies or notices regarding use and disclosure of your medical information.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

  • make sure that medical information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to medical information about you;    and
  • follow the terms of the notice that is currently in effect.

HOW WE ARE REQUIRED BY LAW TO DISCLOSE MEDICAL INFORMATION ABOUT YOU.

  • As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
  • To Avert a Serious Threat to Health or Safety. We will use and disclose medical information about you when we have a “Duty to Report” under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
  • Public Health Risks. We will disclose medical information about you for public health reporting required by federal or state law. These activities generally include the following:
  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a Consumer has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
  • Health Oversight Activities. We will disclose medical information as required by law to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we will disclose medical information about you when properly ordered to do so by a court.
  • Law Enforcement. We will release medical information if asked to do so by a law enforcement official, and if permitted by law:
  • In response to a court order;
  • If required by state or federal law;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at a Forte Residential, Inc., facility; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
  • Protective Services for the President and Others. We will disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

  • For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other Forte Residential, Inc., personnel who are involved in taking care of you. Different departments of the Forte Residential, Inc., also may share medical information about you in order to coordinate the different things you need. We also may disclose medical information about you to people outside Forte Residential, Inc.,, such as other health care providers involved in providing medical treatment for you and to people who may be involved in your medical care, such as family members, clergy or others we use to provide services that are part of your care.
  • For Payment. We may use and disclose medical information about you so that the treatment and services you receive at Forte Residential, Inc.,, or other health care providers from whom you receive treatment, may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received at Forte Residential, Inc., so your health plan will pay us or reimburse you for your treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
  • For Health Care Operations. We may use and disclose medical information about you for Forte Residential, Inc., operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan . These uses and disclosures are necessary to run Forte Residential, Inc., and make sure that all of our Consumers receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Consumers to decide what additional services Forte Residential, Inc., should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other Health Care Rehabilitation Facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific Consumers are.
  • Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at Forte Residential, Inc.,.
  • Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
  • Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
  • Fundraising Activities. Forte Residential, Inc., does not use Consumer information for fundraising purposes.
  • Facility Directory. We may include certain limited information about you in a facility directory while you are a Consumer at a Forte Residential, Inc., facility. This information may include your name, location, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you at the facility and generally know how you are doing.
  • Individuals Involved in Your Care or Payment for Your Care. We may release certain limited 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. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
  • Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all Consumers who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with Consumers’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for Consumers with specific medical needs, so long as the medical information they review does not leave Forte Residential, Inc.,. We may ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the hospital.

SPECIAL SITUATIONS

  • Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
  • Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
  • Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about Consumers of Forte Residential, Inc., to funeral directors as necessary to carry out their duties.
  • National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding medical information we maintain about you:

  • Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to The Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, under some circumstances you may request that the denial be reviewed. Another licensed health care professional chosen by Forte Residential, Inc., will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
  • Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Forte Residential, Inc.,.To request an amendment, your request must be made in writing and submitted to The Privacy Officer. In addition, you must provide a reason that supports your request.We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the hospital;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.
  • Right to an Accounting of Disclosures. You have the right to request an “Accounting of Disclosures.” This is a list of the disclosures we made of medical information about you.To request this list or accounting of disclosures, you must submit your request in writing to The Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 1, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a specific treatment session you had.We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.To request restrictions, you must make your request in writing to The Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
  • Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.To request confidential communications, you must make your request in writing to The Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
  • Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact the Office Manager.

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 in each of our facilities. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at or are admitted to Forte Residential, Inc., for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Forte Residential, Inc., or with the Secretary of the Department of Health and Human Services. To file a complaint with Forte Residential, Inc.,, contact Tom Van Meter, President, 574.528-6398. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

Name of Consumer: _____________________________________________

Consumer’s Signature: ____________________________________________ Date: _________________

Witness’s Signature: _____________________________________________ Date: _________________

Witness’s Signature: _____________________________________________ Date: _________________

Reason Given by Consumer for Refusing to Sign this Notice