Each resident will receive a notice of the uses and disclosures of his/her protected health information (PHI) that may be made by or on behalf of the community, and the resident’s right and our company’s legal duties with respect to the resident’s PHI.


  1. Upon admission to the community, residents will be provided with a copy of our community’s privacy notice relative to protected health information.
  2. Privacy notices are provided in an easy-to-read language and contain, at a minimum, the following elements:
    1. A statement indicating how medical information about the resident may be used and disclosed and how the resident can obtain access to such information;
    2. A description, including at least one example, of the types of uses and disclosures that the community is permitted to make for purposes of treatment, payment and healthcare operations, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required;
    3. A description of each of the other purposes for which the community is permitted or required to use or disclose PHI without the resident’s consent or authorization, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required;
    4. A statement that other uses or disclosures will be made only with the resident’s written authorization, and that the authorization may be revoked in accordance with the policy on authorization;
    5. A description of the types of uses and disclosures that require an authorization;
    6. A separate statement that the community may contact the resident for fundraising activities, and that the individual has the right to opt out of these communications;
    7. A statement of the resident’s rights with respect to his/her PHI, and a brief description of how the resident may exercise those rights, including:
      1.  the right to request restrictions on certain uses/disclosures of PHI, and the fact that the community does not have to agree to such restrictions;
      2. the right to receive confidential communications of PHI;
      3. the right to inspect and copy PHI;
      4. the right to amend PHI;
      5. the right to receive an accounting of disclosures of PHI; and
      6. the right to receive a paper copy of the privacy notice.
    8. A statement of the community’s duties with respect to PHI, including statements:
      1. that the community is required by law to maintain the privacy of PHI and to provide residents with notice of its legal duties and privacy policies;
      2. that the community is required by law to notify affected individuals following a breach of unsecured protected health information;
      3. that the community is required to abide by the terms of its current effective privacy notice; and
      4. that the community reserves the right to change the terms of the notice and make the new notice provisions effective for all PHI maintained, along with a description of how the community will provide residents with the revised notice.
    9. A statement that residents may complain to the community and to the Secretary of the U. S. Department of Health and Human Services about privacy rights violations, including a brief statement about how a complaint may be filed and an assurance that the resident will not be retaliated against for filing a complaint;
    10. The name, or title, and telephone number of the community’s HIPAA compliance officer to contact for further information; and
    11. The effective date of the notice, which may not be earlier than the date printed or published.
  3. A copy of privacy notices issued to residents will be retained for a period of not less than six (6) years from the later of the date of creation or the last effective date
  4. Oral review of privacy notices will be made by the HIPAA compliance officer when such request is made by the resident.
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