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.

a. Treatment - In order to provide you with the healthcare you require, this facility will provide your medical information to those healthcare personnel, whether on this facility's staff or not, directly involved in your care so that they may understand your medical condition and needs;

b. Payment - In order to get paid for services provided, this facility will provide your medical information, directly or through a billing service, to appropriate third party payors, as per their billing and payment requirements; and

c. Healthcare Operations - In order to gain an overall view of various elements of this facility's operations, individual medical information may be collected, compiled and disseminated.

d. De-Identified Information - Information that is not individually identifiable, in accordance with applicable laws, may be freely disclosed by this facility;

e. Business Associate - If this facility obtains satisfactory written assurance from the business associate, in accordance with applicable laws, that the business associate will appropriately safeguard the protected information (for additional information, please refer to section 4 number i);

f. Personal Representative - If under applicable New York law a person has the authority to represent you in making decisions related to your health care;

g. Emergency Situations -

i. For the purpose of obtaining emergency treatment for you - if the facility attempts to obtain consent but is unable to do so; or
ii. To a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities.

h. Communication Barriers - If due to substantial communication barriers or inability to communicate this facility has been unable to obtain consent and this facility determines, in the exercise of its professional judgment, that your consent to receive treatment is clearly inferred from the circumstances;

i. Directory - In order to maintain a directory of individual's in this facility, their location, their condition in non-specific general terms and their religious affiliation. This information can be made available in its entirety to members of the clergy and, except for religious affiliation, to anyone asking for you by name;

1. If, due to incapacity, this facility has been unable to provide an opportunity for agreement or objection and such disclosure is: i. Consistent with your prior expressed preference, if any, that is known to this facility; and

ii. In your best interest as determined by this facility, in the exercise of its professional judgment.

j. Involvement in Care or Payment - In accordance with applicable laws, disclosure may be made to your family member, other relative, close personal friend and/or any other person identified by you, of such information that is relevant to the persons involvement with your care or payment related to your health care;

k. Notification - In order to notify, or assist in the notification of a family member, a personal representative or another person responsible for your care of your location or general condition;

l. Required by Law - When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law;

m. Criminal Conduct - To a law enforcement official, that this facility believes in good faith constitutes evidence of criminal conduct that occurred on the facility premises;

n. Organ Procurement Organizations - Or other entities engaged in the procurement, banking or transportation of organs for the purpose of facilitating organ, eye or tissue donation and transplantation;

o. Threat to Health and/or Safety - If it is necessary to prevent or lessen a serious and imminent threat to the health and/or safety of a person or the public, in accordance with applicable laws; and

p. Appointment Reminders - In order to provide you with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

a. Revoke any authorization and/or consent, in writing, at any time;

b. Request restrictions on certain uses and/or disclosures as provided by law; however, this facility is not obligated to agree to any requested restrictions;

c. Receive confidential communications of protected information as required by law;

d. Inspect and copy protected information as provided by law;

e. Amend protected information as provided by law;

f. Receive an accounting of disclosures of protected information as provided by law;

g. Receive a paper copy of this notice from this facility upon request;

h. Lodge a complaint with this facility or to the Secretary of HHS if you believe your privacy rights have been violated. Please see your Social Worker to file a complaint; and

i. Obtain more information on, or have your questions about your privacy rights answered. You may contact this facility's Privacy Officer, Stanley Farkas @516-942-4789 or via email @ Needtoreport@aol.com.

4. Facility Rights & Requirements - This facility:

a. Is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected information;

b. Is required to abide by the terms of this notice;

c. Reserves the right to change the terms of this notice and to make the new notice provisions effective for all protected information that it maintains.

d. Will: i. Distribute any revised notice at a Resident Council Meeting prior to implementation; and

ii. Given to you and you will be requested to sign a receipt for any revised notice. e. Will not retaliate against you for filing a complaint;

5. This original notice is in effect as of April 14, 2003.
 
6. I have received a copy of this "privacy notice for residents" via the Marquis Care Center website.

Notice Received by (Print Name) _______
Signature of Recipient _______ Date Received ___/___/____
NOTES: ________________________________________________________ _______________________________________________________________