Fred Lind Manor

Privacy Policy

EXHIBIT 12

PRIVACY STATEMENT – HEALTH CARE RECORDS

THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1974. THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.

AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER AND WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY.

Sections 1819(1), 1919(f), 1819(b) (3) (A), 1919(b) (3) (A), and 1864 of the Social Security Act.

Medicare participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. To implement this requirement, Park Shore must obtain information from every resident. This information also is used by the Federal Center for Medicare and Medicaid Services (CMS) to ensure that Park Shore meets quality standards and provides appropriate care to all residents. For this purpose, as of June 22, 1998, all such facilities are required to establish a database of resident assessment information, and to electronically transmit this information to CMS.

Because the law requires disclosure of this information to Federal and State sources as discussed above, a resident does not have the right to refuse consent to these disclosures.

The data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of records.

1. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED.

The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services.

2. ROUTINE USES

The primary use of this information is to aid in the administration of the survey and certification of Medicare/Medicaid long term care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory reimbursement, policy and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purpose.

The information collected will be entered into the Long-Term Care Minimum Data Set (LTC MDS) systems of records. System No. 09-70-1517. Information from this system may be disclosed under specific circumstances, to: (routine uses), which include: To the Census Bureau and to:(1) Agency contractors, or consultants who have been engage by the Agency to assist in accomplishment of a CMS function, (2) another Federal or a Federal/State Medicaid program and to contribute to the accuracy of reimbursement made for such programs, (3) to Quality Improvement Organizations (QIOs) to perform Title XI or Title XVIII functions, (4) to insurance companies, underwriters, third party administrators (TPA), employers, self-insurers, group health plans, health maintenance organizations (HMO) and other groups providing protection against medical expenses to verify eligibility for coverage or to coordinate benefits with the Medicare program, (5) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability or the restoration of health, or payment related projects, (6) to a member of Congress or congressional staff member in response to an inquiry from a constituent, (7) to the Department of Justice, (8) to a CMS contractor that assists in the administration of a CMS-administered health benefits program or to a grantee of a CMS-administered grant program, (9) to another Federal agency or to an instrumentality of any governmental jurisdiction that administers, or that has the authority to investigate potential fraud or abuse in a health benefits program funded in whole or in part by Federal funds to prevent, deter, and detect fraud and abuse in those programs, (10) to national accrediting organizations, but only for those facilities that these accredit and that participate in the Medicare program…

3. EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION

The information contained in the Long Term Minimum Data Set is generally necessary for facility to provide appropriate and effective care to each resident. If a resident fails to provide such information, for example on medical history, inappropriate and potentially harmful care may result. Moreover, payment for such services by third parties, including Medicare and Medicaid, may not be available unless Park Shore has sufficient information to identify the individual and support a claim for payment.

EXHIBIT 13

NOTICE OF PRIVACY INFORMATION PRACTICES

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. PURPOSE OF THE NOTICE

Park Shore is committed to preserving the privacy and confidentiality of your health information, which is created and/or maintained at Park Shore. State and Federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information. This notice will provide you with information regarding our privacy practices and applies to all of your health information created and/or maintained at Park Shore, including any information that we receive from other health care providers or facilities. The Notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations concerning such uses or disclosures.

We will abide by the terms of this Notice, including any future revisions that we may make to the Notice as required or authorized by law. We reserve the right to change this Notice and to make the revised or changed Notice effective for health 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, which will identify its effective date, in Park Shore.

The privacy practices described in this Notice will be followed by:

1. Any health care professional authorized to enter information into your medical record created and/or maintained at Park Shore;

2. All employees, students, and other service providers who have access to your health information at Park Shore; and

3. Any member of a volunteer group, which is allowed to help while you are receiving services at Park Shore.

B. USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

1. Treatment, Payment and Health Care Operations. The following section describes different ways that we may use and disclose your health information for purposes of treatment, payment and health care operations. We explain each of these purposes below and include examples of the types of uses or disclosures that may be made for each purpose. We have not listed every type of use or disclosure, but the ways in which we use or disclose your information will fall under one of these purposes.

a. Treatment. We may use your health information to provide you with health care treatment and services. We may disclose your health information to doctors, nurses, nursing assistants, medication aides, technicians, medical and nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care.

For example, we may order physical therapy services to improve your strength and walking abilities. We will need to talk with the physical therapist so that we can coordinate services and develop a plan of care. We also may need to refer you to another health care provider to receive certain services. We will share information with that health care provider in order to coordinate your care and services.

b. Payment. We may use or disclose your health information so that we may bill and receive payment from you, an insurance company, or another third party for the health care services you receive from us. We also may disclose health information about you to your health plan in order to obtain prior approval for the services we provide to you, or to determine that your health plan will pay for the treatment

c. Health Care Operations. We may use or disclose your health information in order to perform the necessary administrative, educational, quality assurance and business functions of Park Shore.

For example, we may use your health information to evaluate the performance of our staff in caring for you. We also may use your health information to evaluate whether certain treatment or services offered by Park Shore are effective. We also may disclose your health information other physicians, nurses, technicians, or health profession students for teaching and learning purposes.

C. USES AND DISCLOSURES OF HEALTH INFORMATION IN SPECIAL SITUATIONS

We may use or disclose your health information in certain special situations as described below. For these situations, you have the right to limit these uses and disclosures as provided for this Notice.

1. Appointment Reminders. We may use or disclose your health information for purposes of contacting you to remind you of a health care appointment.

2. Treatment Alternatives & Health-Related Products and Services. We may use or disclose your health information for purposes of discussing with you treatment alternatives or health-related products or services that may be of interest to you. For example, if you are a resident of Park Shore for purposes of a post-surgical hip replacement, we may talk with you about a gait-training program that we offer at Park Shore to improve your walking and balance.

3. Care Center Directory. We may use or disclose certain limited health information about you in Park Shore directory. This information may include your name, your assigned unit and room number, your religious affiliation, and a general description of your condition. Your name, assigned unit and room number, and a general description of your condition may be given to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, even if they do not ask for you by name.

4. Family Members and Friends. We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care. We may make such disclosures when: (a) we have your verbal agreement to do so; (b) we make such disclosures and you do not object; or (c) we can infer from the circumstances that you would not object to such disclosures. For example, we will share information about you with your spouse or other family member after giving you an opportunity to agree or object.

We also may disclose your health information to family members or friends in instances when you are unable to agree or object to such disclosures, provided that we feel it is in your best interest to make such disclosures and the disclosures relate to that family member or friend's involvement in your care. For example, if your medical condition prevents you from either agreeing or objecting to disclosures made to your family or friends, we may share information with the family member or friend that comes to visit you at Park Shore, but we will share only that information which relates to their involvement in your care.

D. OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH INFORMATION

There are certain instances in which we may be required or permitted by law to use or disclose your health information without your permission. These instances are as follows:

1. As Required by Law. We may disclose your health information when required by federal, state, or local law to do so. For example, we are required by the Department of Health and Human Services (DHS) to disclose your health information in order to allow DHS to evaluate whether we are in compliance with the federal privacy regulations.

2. Public Health Activities. We may disclose your health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury, or disability; to report births, deaths, suspected abuse, or neglect, reactions to medications; or to facilitate product recalls.

3. Health Oversight Activities. We may disclose your health information to a health oversight agency that is authorized by law to conduct health oversight activities, including audits, investigations, inspections, or licensure and certification surveys. These activities are necessary for the government to monitor the persons or organizations that provide health care to individuals and to ensure compliance with applicable state and federal laws and regulations.

4. Judicial or Administrative Proceedings. We may disclose your health information to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes. We may disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if efforts have been made to (a) notify you of the request for disclosure or (b) obtain an order protecting your health information.

5. Worker's Compensation. We may disclose your health information to worker's compensation programs when your health condition arises out of a work-related illness or injury.

6. Law Enforcement Official. We may disclose your health information in response to a request received from a law enforcement official to report criminal activity or to respond to a subpoena, court order, warrant, summons, or similar process.

7. Coroners, Medical Examiners, or Funeral Directors. We may disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may disclose your health information to a funeral director for purpose of carrying out his/her necessary activities.

8. Organ Procurement Organizations or Tissue Banks. If you are an organ donor, we may disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation or transplantation.

9. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information may be used or disclosed has been approved through this special approval process. However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying patients with specific health care needs who may qualify to participate in the research project. Any use or disclosure of your health information which is done for the purpose of identifying qualified participants will be conducted onsite at Park Shore. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address or other identifying information.

10. To Avert a Serious Threat to Health or Safety. We may use or disclose your health information when necessary to prevent a serious threat to the health or safety of you or other individuals.

11. Military and Veterans. If you are a member of the armed forces, we may use or disclose your health information as required by military command authorities.

12. National Security and Intelligence Activities. We may use or disclose your health information to authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities, as authorized by law.

13. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclose your health information to the correctional institution or to the law enforcement official as may be necessary (a) for the institution to provide you with health care; (b) to protect the health or safety of you or another person; or (c) for the safety and security of the correctional institution.

E. USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION

Except for the purposes identified above in Sections B through D, we will not use or disclose your health information for any other purposes unless we have your specific written authorization. You have the right to revoke a written authorization at any time as long as you do so in writing. If you revoke your authorization, we will no longer use or disclose your health information for the purposes identified in the authorization, except to the extent that we have already taken some action in reliance upon your authorization.

F. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding your health information. You my exercise each of these rights, in writing, by providing us with a completed form that you can obtain from the business office. In some instances, we may charge you for the cost(s) associated with providing you with the requested information. Additional information regarding how to exercise your rights, and the associated costs, can be obtained from the business office.

1. Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed.

2. Right to Amend. You have the right to request an amendment of your health information that is maintained by or for Exeter House and is used to make health care decisions about you. We may deny your request if it is not properly submitted or does not include a reason to support your request. We may also deny your request if the information sought to be amended: (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the information that is kept by or for Exeter House; (c) is not part of the information which you are permitted to inspect and copy; or (d) is accurate and complete.

3. Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures of your health information made by us. This accounting will not include disclosures of health information that we made for purposes of treatment, payment, or health care operations or pursuant to a written authorization that you have signed.

4. Right to Request Restrictions. You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment of your care. For example, you could ask that we not use or disclose information regarding a particular treatment that you received. We are not required to agree to your request. If we do agree, that agreement must be in writing and signed by you and us.

5. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health care in a certain way or at a certain location. For example, you can ask that we only contact you by mail.

6. Right to a Paper Copy of this Notice. You have the right to receive 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.

G. QUESTIONS OR COMPLAINTS

If you have any questions regarding this Notice or wish to receive additional information about our privacy practices, please contact our Privacy Officer. If you believe your privacy rights have been violated, you may file a complaint with Exeter House or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Exeter House, contact our Privacy Officer at Exeter House. All complaints must be submitted in writing. You will not be penalized for filing a complaint.




privacy policy
1802 17th Avenue, Seattle, WA 98122
206-324-1632