slow the healing process.  In addition, the Provider may need to tell the dietician if you have diabetes so that the dietician can arrange for appropriate meals.  Different departments of the Provider also may share protected health information about you in order to coordinate the different things you need.  We also may disclose protected health information about you to people outside the Provider who may be involved in your medical care when you are absent from the Provider, such as family members, clergy, providers of day services, volunteers, Independent Support Coordinators, case managers, respite care workers and others we have engaged to provide services that are part of your care.

 Ø   For Payment:  We may use and disclose protected health information about you so that the treatment and services you receive from the Provider or other providers may be billed to and payment may be collected from you, the government, an insurance company or a third party.  For example, we may disclose information to the county or state mental health and/or mental retardation agency in order to receive payments for your treatment.  We may also tell your insurer or governmental payor about a treatment you are going to receive to obtain prior approval or to determine whether your plan or the government will cover the cost of the treatment.

 Ø  For Health Care Operations:  We may use and disclose protected health information about you for Provider operations or operations of another provider or payor.  These uses and disclosures are necessary to run the Provider and make sure that all of our clients receive quality care.  For example, we may use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you.  We may also combine protected health information about many Provider clients to decide what additional services the Provider should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to doctors, nurses, technicians, medical students, direct care providers, behavioral therapists, special therapists and other Provider personnel for review and learning purposes.  We may also disclose information in order to comply with our incident reporting requirements under state, local or federal law.  We may also combine the protected health information we have with protected health information for other providers 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 protected health information so others may use it to study health care and health care delivery without learning who the specific clients are.

 Ø  Health Care Quality Units and Other Quality Review Organizations:  We may disclose information to the Pennsylvania Department of Public Welfare, the Office of Mental Retardation and other state and county mental health and mental retardation agencies through their appointed agents, including Health Care Quality Units and independent monitoring groups, in order to comply with Federal, state and local laws and regulations.

 Ø  Appointment Reminders:  We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at the Provider.

 Ø  Treatment Alternatives:  We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

 Ø  Health-Related Benefits and Services:  We may use and disclose protected health information to tell you about health-related benefits or services that may be of interest to you.

 Ø  Fundraising Activities:  We may use contact information, such as your name, address and phone number, and the dates you received treatment or services from the Provider to contact you and your family members in an effort to raise money for the Provider.  We may disclose this contact information to a foundation related to the Provider so that the foundation may contact you and your family members in raising money for the Provider.  If you do not want the Provider or the foundation to contact you or your family members for fundraising efforts, you must notify the Privacy Officer in writing.

 Ø  Provider Directory:  We may include certain limited information about you in the Provider directory while you are a client of the Provider.  This information may include your name, location at the Provider, your general condition 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 do not ask for you by name.  This is so your family, friends and clergy can visit you at the Provider and generally know how you are doing.

 Ø  Individuals Involved in Your Care or Payment for Your Care:  We may disclose protected health information about you to your family members, your personal friends or any other person identified by you, but we will only disclose information that we feel is relevant to that person’s involvement in your care or the payment for your care.  If you are feeling well enough to make decisions about your care, we will follow your directions as to who is sufficiently involved in your care to receive information.  If you are not present or cannot make these decisions, we will make a decision based on whether we believe it is in your best interest for a family member or friend to receive private health information and how much information they should receive.  Obviously, we are inclined to provide greater information to close family members than to friends.

      We may also disclose information to disaster relief agencies or to family, friends or others in an effort to locate or identify family members or personal representatives.

 Ø  Research:  Under certain circumstances, we may use and disclose protected health information about you for research purposes.  For example, a research project may involve comparing the progress of all clients who received one therapy 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 protected health information, trying to balance the research needs with clients’ need for privacy of their protected health information.  Before we use or disclose protected health information for research, the project will have been approved through this research approval process, but we may, however, disclose protected health information about you to people preparing to conduct a research project, for example, to help them look for clients with specific medical needs, so long as the protected health information they review does not leave the Provider.  In certain situations, we are required to ask your specific permission, such as when 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 Provider.

 Ø  As Required By Law:  We will disclose protected health information about you when required to do so by federal, state or local law.  For instance, the Provider is obligated to report to public health officials the occurrence of certain communicable diseases, or acts of violence.  Additionally, the Provider is required to report certain incidents to the Pennsylvania Department of Public Welfare.

 Ø  To Avert a Serious Threat to Health or Safety:  We may use and disclose protected health information about you when 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.

 Ø  Day Providers:  We may use and disclose information about you if necessary to facilitate your application for admission to, or use of, day programs such as supported employment and sheltered employment.

 Ø  Residential Facilities:  We may use and disclose information about you if necessary to facilitate your application for admission into, or use of, residential facilities.

 Ø  In-home Services:  We may use and disclose information about you if necessary to facilitate your application for, or use of, in-home services.

 Ø  Family Living Arrangements:  We may use and disclose information about you if necessary to facilitate your application for admission into, or use of, family-living arrangements.

 Ø  Supports Coordinators:  We may use and disclose information about you as necessary for supports coordinators and case managers to complete their duties for you.

 Ø  Transfers:  We may use and disclose information about you to another Provider to which you are being transferred or which is considering you as a transfer.

 Ø  Employers:  We may use and disclose information about you to an employer or prospective employer in connection with your application for, or continuation of, employment.

SPECIAL SITUATIONS

 Ø  Organ and Tissue Donation:  If you are an organ or tissue donor, we may release protected health 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.

 Ø  Military and Veterans:  If you are a member of the armed forces, we may release protected health information about you as required by military command authorities.  We may also release protected health information about foreign military personnel to the appropriate foreign military authority.

 Ø  Worker’s Compensation:  We may release protected health information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.  Under the privacy regulations, workers’ compensation claims are exempted from coverage, and thus we may release protected health information about you to your employer for workers’ compensation purposes.

 Ø  Public Health Risks:  We may disclose protected health information about you for public health activities.  These activities generally include the following:

·         To prevent or control disease, injury or disability;

·         To report birth 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 client 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.

Ø  Health Oversight Activities:  We may disclose protected health information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections and licensure.  The federal government has determined that it must have access to this information to adequately monitor beneficiary eligibility for government programs (for example, Medicare or Medicaid), compliance with program standards and/or civil rights laws.

Ø  Lawsuits and Disputes:  If you are involved in a lawsuit or a dispute, we may dis-close protected health information about you in response to a court or administrative order.  We may also disclose protected health information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if appropriate efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Ø  Law Enforcement:  We may release protected health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;

• 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 the Provider; 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.

 Ø  Coroners, Medical Examiners and Funeral Directors:  We may release protected health 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 protected health information about clients of the Provider to funeral directors as necessary to allow them to carry out their duties.

 Ø  National Security and Intelligence Activities:  We may release protected health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

 Ø  Protective Services for the President and Others:  We may disclose protected health 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.

 Ø  Inmates:  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health 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 protected health information we maintain about you:

 Ø  Right to Inspect and Copy:  You have the right to inspect and copy protected health 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 protected health 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 customarily 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 protected health information, you may request that the denial be reviewed.  Another licensed health care professional chosen by the Provider 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.

 Ø  Right to Append and Amend:  If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to append or amend the information.  You have the right to request an amendment for as long as the information is kept by or for the Provider.  If we do not agree to amend your information, you may add a supplemental statement to your records indicating why you believe the information should be changed.  We will append or otherwise link your statement to your records.

      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 protected health information kept by or for the Provider;

• Is not part of the information which you would be permitted to inspect and copy; or

• Is accurate and complete.

 Ø  Right to an Accounting of Disclosures:  You have the right to request an “accounting of disclosures.”  This is a list of several types of the disclosures we made of protected health 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 February 26, 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.

 Ø  Right to Request Restrictions:  You have the right to request a restriction or limitation on the protected 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 protected health 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 surgery 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.

 Ø  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

 Ø  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.

      You may obtain a copy of this notice at our website, www.bcrc.net

      To obtain a paper copy of this notice, please write to:

 Sandy Rizzo, Privacy Officer

 Beaver County Rehabilitation Center, Inc.

 1517 Sixth Avenue

 New Brighton, PA  15066-2219

 Or call at 724-847-1306

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 protected 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 at our site.  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 the Provider for treatment or health care services as a client, 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 the Provider or with the Secretary of the Department of Health and Human Services.  To file a complaint with the Provider, contact Sandy Rizzo, Privacy Officer, Beaver County Rehabilitation Center, 1517 Sixth Avenue, New Brighton, PA  15066-2219.  All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF PROTECTED HEALTH INFORMATION

Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization.  If you provide us permission to use or disclose protected health 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 protected health information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

NOTICE OF PRIVACY PRACTICES

 I acknowledge that I have received a copy of Beaver County Rehabilitation

    Center, Inc.’s Notice of Privacy Practices.

________________________________________      _________________

                          Signature                                                           Date