- Holland Home and its subsidiaries
- Any health care professional authorized to enter information into your medical file
- All departments, units and wholly-owned subsidiaries of Holland Home
- Any professional care provider or member of a volunteer group we allow to help you while
you are in any Holland Home facility
- All employees, clinical staff and other non-clinical personnel
In this Notice, each reference to “we” is meant to include all of the above entities, providers,
sites, and locations. Any or all of these entities, providers, sites, and locations may share
information about you for treatment, payment or health care operation purposes described in this
Notice. Each reference to “you” or “your” is intended to include the resident and any person
legally authorized and appointed to act on behalf of the resident in connection with the resident’s
medical care.
Any time you reside in a Holland Home independent living, assisted living, or skilled nursing
facility, or are being served by any Holland Home agency, a record of the medical or health related
care you receive during your stay is recorded in a medical file. Typically, this file contains
information regarding your health history, symptoms, examinations and tests performed including the
results of those tests, any diagnoses or treatment and any plan for future care or follow-up with
respect to condition or treatment. Some of this information may be collected from other health care
providers. This information is often referred to as your health or medical record. When we create a
record or collect this type of health information about you, we use it for current and administrative
and operational purposes, and to evaluate the quality of the care we are providing you. By way of
example, we may use or disclose certain identifiable health information about you, with out your
authorization for reasons such as:
- A means of our communication with other health professionals who contribute to or participate
in your care while you are our resident; including doctors, nurses, technicians, students and
other clinical personnel involved in taking care of you, as well as people outside of our
organization who may be involved in your health care, such as family members, pastoral care
or others who provide services that are part of your care. For example, we may need to
disclose information about whether you have diabetes to a doctor treating you for a broken
bone or an infection because diabetes can slow the healing process
- A means for preparing documentation relating to your treatment that we are required by law
to maintain and, in some cases, give out for public health purposes, abuse or neglect
reporting, auditing purposes, research studies, funeral arrangements and organ donation,
workers’ compensation purposes and emergencies
- A means by which you or a third party payer can verify services provided to you so that we may
bill for or receive payment from you, an insurance company or other third party payer, or
person responsible for paying for any of your care. For example, we may need to give your
health plan information about treatment you received so the plan will pay us for the care
we provided
- A source of data in our daily operations as a health care provider. For example, we may need
to use your health information and record as a tool in educating and assessing the competency
of doctors, nurses and technicians who provide care here
- A source of data to provide to staff and residents as we attempt to foster a feeling of
community among our residents, thereby improving the quality of your stay and hopefully
improving the environment for your health and healing. For example, we may post your
name, birthday, or other general information about you in newsletters or on bulletin board
in your facility
- A source of data for advising you of possible treatment options or alternatives and other
health-related benefits or services that may be of interest to you
- A source of data for use in identifying potential philanthropic support
- A source of data for a facility directory to be used while you are a resident of ours,
including your name, phone number, and location in the facility
- A source of information for public health officials charged with improving the health of our
city, state, and nation, or responsible for averting a serious threat to your health or the
safety of you, another person or the public
- A tool used to assess and continually work toward improving the overall quality of care we
render and the outcomes we achieve
- Information required to be disclosed by federal, state, or local law
- A source of data for an appropriate joint treatment, payment or operational activity of
Holland Home and its subsidiaries, Homecare of Holland Home and Hospice of Holland Home
- A source of data for organizations that handle organ procurement, transplant or donation as
necessary to facilitate appropriate donation and transplant in the event you are an organ donor
- A source of data and information for health oversight agencies in connection with legally
authorized activities related to the investigation, inspection and licensure of health
care providers
- A source of data and information in connection with a legal dispute or lawsuit in which
you are involved, in response to a court or administrative order, subpoena or other
discovery request, as permitted by law
We routinely provide patient health information when otherwise required by law, such as when
law enforcement officials are entitled to such information in specific circumstances. In any
other instance, we will ask for written authorization before using or disclosing any identifiable
health information about you. If we request one and you choose to sign an authorization to disclose
your protected health information, you can later revoke that authorization to stop future uses and
disclosure of that information without your consent.
We may change our policies or practices regarding the use of your health information from time to
time. Before we make significant change in our policies or practices, we will change our notice
and post the new notice in common areas in our facilities. You have a right to a written copy of
this notice, and can always at any time request a copy of our current notice. For more information
about our privacy practices and policies, please contact the individual and office listed below.
Although your health record is the physical property of Holland Home, the information contained
within your health record belongs to you. You have a right to request the restriction of certain
uses and disclosures of your information. You also have the right to amend and request changes
in the information contained within your health record and to obtain an accounting of disclosures
of your health information when such disclosures are made for other than treatment, payment or
related administrative or operating purposes as described above. Any request to amend your record
must be made in writing and we may deny your request if it:
- is not in writing
- does not include a reason to support the request
- the health information or record that is the subject of the request
- was created by another health care provider
- is not part of the health information kept by or for our organization
- is not part of the health information you would be permitted to inspect or copy
- is accurate and complete as is
Any request for an accounting of disclosures of your information must be in writing, can be for a
time period no longer than six years and may not include a period of time prior to April 14, 2003.
The first disclosure list you request within a 12-month period is free. For any additional
request, we may charge you for the cost of providing the list.
You may request, in writing, that we not use or disclose your information for treatment, payment or
administrative purposes except when specifically authorized by you, when required by law, or
emergency circumstances. We will consider your request, but you should be aware that we are not
legally required to accept it and may, if we deem your request too restrictive, elect not to
treat you or to disregard it in an emergency situation. You have the right to restrict or
prohibit some or all of the uses or disclosures of your information from the facility’s directory.
You have the right, with limited exceptions, to inspect and obtain a copy of your health record.
Usually this includes medical and billing records, but may not include records such as psychotherapy
notes. If you request copies of your health records, the request must be in writing and we will
charge you for such copies. This charge is directly attributable to the administrative and copying
costs associated with meeting your request. If your request for copies of your health record is,
in your opinion, an emergency, please let us know, as we do not intend to deny you access to your
health records or information in an emergency circumstance and will work with you to meet these
emergency needs.
You also have the right to request that we communicate with you about medical matters in certain
ways or at certain locations. Again, this request should be in writing and should be specific
as to how and where you wish to be contacted. We do not need to know the reasons for your request.
We are required by law to maintain the privacy of your health information, provide you with
this notice of our legal duties and privacy practices, and to abide by the terms of this Notice.
If you are concerned that we have violated your privacy rights or our own policies as summarized
in this Notice, or if you disagree with a decision we made about access to your records, you may
contact the person listed below. You may also send a written complaint to the United States
Department of Health & Human Services. The person and office listed below can provide you with
the appropriate address upon request. You will not suffer any retaliation for filing a complaint.
We are required by law to protect the privacy of your information and to provide you with this
Notice about our information practices. We are also required to abide by the terms of this Notice
and to notify you if we are unable to agree to a requested restriction you have made relative to
the use or disclosure of your information. In addition, we are required to accommodate reasonable
requests you make regarding the communication of your health information by alternate means or at
alternative locations.
If you have any questions regarding this Notice, our use or disclosure of your health information
or wish to file a complaint regarding our use or disclosure of your health information, please
contact the Holland Home Privacy Officer at 1-616-235-5678 or the U.S. Secretary of Health
and Human Services, HIPAA Complaint, 7500 Security Blvd. C5-24-04, Baltimore, MD 21244.
Effective Date of this Notice: April 14, 2003
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