Privacy Statement

NOTICE OF PRIVACY 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.

The Ohio Masonic Home and its corporate subsidiaries (the "Facility") maintain records about you in order to provide services to you. State and federal laws restrict how the Facility uses and discloses your personal health information. This Notice describes how the Facility may use or disclose your personal health information and other rights that you may have with respect to your information.

The Notice of Privacy Practices in its entirety shall be inclusive as the Facility's policy and procedure concerning the Privacy Rule.

I. Scope of this Notice.

This notice applies to the Facility and its employees as well as staff physicians who provide medical care to the residents at the facility as part of an Organizational Health Care Arrangement (OHCA). The Facility also has business associate agreements with specialists, which include, but are not limited to: podiatrists, dentists, optometrists and other medical professionals who provide needed services. The Facility shares resident health information with the physicians and other health care professionals for the purposes of providing treatment, obtaining payment and carrying out health care operations. These functions are described more fully in the following sections.

These physicians and other health care professionals are bound by the same laws concerning the privacy of your health information and have agreed to abide by the terms of this Notice of Privacy Practices.

II. Treatment, Payment and Healthcare Operations.

The three primary purposes for which the Facility may use or disclose your personal health information involve providing treating, obtaining payment, and carrying out healthcare operations. Generally, the Facility may use your health information for its own purposes or disclose the information to another healthcare provider for purposes of providing treatment to you or obtaining payment for services rendered to you. The Facility may also use your personal health information to carry out healthcare operations and in certain limited circumstances, disclose your information to assist another provider in carrying out healthcare operations.

The Facility may use health information that it receives or collects about you to provide treatment to you. For example, the Facility may consult with your physician and use the information that it receives from you and from your medical record to develop a plan of care for you.

The Facility may also disclose your personal health information to assist another healthcare provider with providing treatment to you. For example, if you are taken to the hospital emergency room, the Facility may disclose information from your medical records to doctors and nurses at the emergency room as necessary to aid in diagnosis and treatment of your condition.

The Facility may also use your personal health information to obtain payment for services rendered to you. Payment activities include billing you directly or billing your insurance carrier or other third party payer for services provided to you. Payment activities also include verifying your insurance coverage or eligibility for benefits. For example, the Facility may disclose information concerning particular services provided to you to your insurance carrier for purposes of verifying that the services are covered under your policy of insurance.

The Facility may also disclose your personal health information to assist another healthcare provider in obtaining payment for services provided to you. For example, you may receive treatment from your primary care physician. If your physician does not already have your insurance information, such as your policy or other identification number, the Facility may provide the information necessary for your physician to submit a claim to your insurance carrier for payment.

The Facility may also use your personal health information to carry out health care operations. Health care operations include functions such as quality improvement, reviewing the competence and qualification of physicians and other healthcare professionals, obtaining and maintaining accreditations, certification, licensing and credentialing, obtaining legal and auditing services including fraud detection, business planning, business management and administration including complying with applicable privacy laws and regulations and resolving internal grievances.

An example of the use of personal health information in conducting healthcare operations would be quality improvement activities relating to staff training. In conducting quality improvement activities, the Facility may review medical records of a sampling of residents. If the review identifies areas where care can be improved, the Facility provides training to staff members in those particular areas to improve quality of care for all residents.

In certain limited circumstances, the Facility may also provide your personal health information to assist another health care provider in carrying out its own healthcare operations. The Facility is limited to assisting other healthcare providers with carrying out quality improvement and competence review activities and fraud and abuse detection. For example, there are certain patterns of activity that sometimes indicate a healthcare provider is using fraudulent billing practices. A local hospital might recognize one such pattern of activity in a physician treating patients at the hospital. The Facility could provide information to the hospital about residents of the Facility treated by the same physician to help determine whether further investigation is warranted.

III. Opportunity to Agree or Object.

In some circumstances, the Facility is permitted to use or disclose your personal health information but must first give you the opportunity to agree or object either orally or in writing. The following instances are not inclusive.

One such situation involves the Resident Directory maintained by the Facility. Unless you notify us that you object, the Facility may use your name, location in the facility and telephone number for directory purposes. This information may be provided to people who ask for you by name. Additionally, such information may be provided to clergy or pastoral care staff who ask for you by name unless you notify the Facility that you object.

Individuals concerned with and involved in your care include other residents who are part of the Facility community. The Facility may make certain disclosures of your information to other residents, such as using your name on a nameplate next to or on your door in order to identify your room. The Facility may also communicate general information of your status or condition, such as including your name on the designated hospital board. The Facility may communicate special events, such as the day and month of your birthday and anniversary, in a social context. The Facility may also disclose other information in a social context through the Facility's publications and internal media.

The Facility may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. If the Facility is unable to reach your family member or personal representative, the Facility may then leave a message for them at the phone number that has been provided by you, e.g., on an answering machine.

The Facility may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health information relevant to that person's involvement in your care or payment related to your care.

Please contact the Privacy Officer at the Facility if you object to any of these or any similar disclosure of your health information.

IV. Disclosures Required by Law.

In certain circumstances, the Facility is authorized or required by law to disclose your personal information without first notifying you or obtaining your consent.

The Facility is required to disclose information requested by the Secretary of the United States Department of Health and Human Services or when any other State or federal law requires disclosure of the information. The Secretary of Health and Human Services may request any information needed to verify that the Facility is in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). When a State or federal law other than HIPAA requires the Facility to disclose health information, the Facility may disclose only as much information as is necessary to comply with the specific requirements of the law.

Ohio law contains a number of provisions that require the Facility to disclose health information about individual residents. Licensed health professionals must report suspected cases of abuse or neglect of a nursing facility or residential care facility resident to the Ohio Department of Health. Similarly, suspected cases of abuse and neglect involving an individual in an independent living environment must be reported to the County Department of Job and Family Services. Finally, the Ohio Department of Health may review any records needed to verify that the Facility is in compliance with applicable licensing requirements

The Facility is also permitted to release information necessary for public health activities. Public health activities include functions of agencies authorized to collect and receive information needed to prevent and control disease. An example of a public health activity would be the Facility reporting a suspected case of a communicable disease to the local Health District or the Ohio Department of Health. Public health activity also includes identifying and notifying individuals who may have been exposed to a suspected case of a communicable disease.

The Facility is authorized to disclose health information as necessary to assist with health oversight activities. Health oversight activities are functions of governmental agencies with authority over licensed health care facilities and professionals. These activities include auditing health care providers, inspecting facilities, conducting civil, criminal and administrative investigations, verifying compliance with licensure requirements and taking disciplinary action against individuals or facilities.

If certain requirements are met, the Facility may release health information in connection with a judicial or administrative proceeding. An Order issued by a Court or administrative tribunal is sufficient to require the Facility to release the information requested. A subpoena, discovery request or other legal process that is not accompanied by an Order from the Court or administrative tribunal must meet certain additional requirements before the Facility may release requested information. Specifically, the party requesting the information must satisfy the Facility that the party has made a reasonable effort to notify the individual or has sought a protective order from the appropriate judicial or administrative body limiting the information to be disclosed and the purposes for which the information will be used.

Under a number of circumstances, the Facility may release information to assist law enforcement agencies. The Facility may report information as required by law such as the requirement to report cases of abuse or neglect or in response to a Warrant, Grand Jury Subpoena, or other Court Order. The Facility may also report limited information needed to identify or locate an individual suspected of committing a crime, a fugitive, a material witness or a missing person. If there is reason to believe an individual died as a result of criminal conduct, the Facility may report information concerning the decedent. The Facility may also disclose information concerning the victim of a crime if the victim agrees to the disclosure or the information is necessary for immediate law enforcement activity against someone other than the victim and the disclosure is in the victim's best interest.

If a crime has been committed on the premises, the Facility may disclose information that it has a good faith to believe is evidence of the crime. Similarly, in an emergency situation, the Facility may disclose information relevant to establishing the commission or nature of a crime, location of a crime, or victims of the crime, or the identity, description or location of a suspected perpetrator of the crime

The Facility is authorized to make certain disclosures concerning decedents. Specifically, the Facility may disclose information required by a coroner, medical examiner, or funeral director to assist in carrying out his or her duties. The Facility may also disclose information to an organization or entity engaged in collecting cadaveric organs, eyes and tissues for donation.

In certain circumstances, the Facility may disclose health information about its residents for research purposes. Ordinarily, disclosure of health information for research purposes requires the individual's specific authorization for the disclosure. However, an institutional review board or a privacy board organized under guidelines established by federal law may waive the authorization requirement for purposes of a specific research project. The Facility may also disclose information without individual authorization to a researcher who requires access to the information to prepare research protocols and who agrees not to remove any of the information from the facility. Similarly, the Facility may disclose information about decedents to assist in a research project based solely on information about decedents.

The Facility may disclose health information necessary to prevent a serious threat to the health or safety of an individual or the public in general. This would be applicable in a situation where the Facility has information that a particular individual poses a serious or imminent threat to his or her own health or safety or the health and safety of another. This would also apply to information necessary to identify and apprehend an individual who has admitted participation in a violent crime or who has escaped from a correctional institution or other lawful custody.

Finally, the Facility may disclose health information as necessary to assist in certain specialized governmental functions. Specialized governmental functions include military affairs such as determining eligibility for veteran's administration benefits, and national security purposes such as intelligence, counter-intelligence and other activities authorized by the National Security Act. The Facility may also disclose information necessary to assist in protective services for the President of the United States and others authorized by law. This includes assisting an investigation into a threat made against the President.

Other Uses and Disclosures.

Other than as described in this Notice, the Facility will not use or disclose your health information without your specific written authorization. If you provide your authorization, you have the right to revoke the authorization at any time. Your revocation of the authorization must be in writing. Also, your revocation is not effective to the extent the Facility has taken action in reliance on your original authorization.

VI. Special Notices.

The Facility may use your personal health information to contact you concerning health related matters in which might interest you. This includes contacting you to remind you of upcoming appointments. This also includes contacting you to provide you with information about possible treatment alternatives or other health related benefits or services that may be useful to you.

The Facility may use limited information about you to contact you about the Facility's fund-raising activities. Specifically, the Facility may use information concerning your name, address, and dates of admission or discharge to contact you about fund-raising. The Facility may also share information with The Ohio Masonic Home Benevolent Endowment Foundation, Inc. (the "Foundation"), an affiliated company, to assist in fund-raising activities.

You have the right to opt out of receiving fund-raising information from the Facility or the Foundation. If you wish to opt out of receiving fund-raising information, we request that you provide the Facility with written notice of your intentions. If you would like additional information on opting out of receiving fund-raising information, you may contact Benevolent Endowment Foundation at the (937) 525-3003.

VII. Individual Rights.

You have additional rights to monitor and control how your personal health information is used by the Facility. These rights include the right to request restrictions on certain uses and disclosures of information, the right to receive confidential communications of personal information, the right to inspect and copy personal information, the right to request an amendment to personal information, the right to receive an accounting of disclosures of personal information and the right to a paper copy of the Facility's Notice of Privacy Practices. This Section contains a description of each of these rights.

A. Right to Request Additional Restrictions.

You have the right to request restrictions on the use of your personal information that are in addition to the restrictions otherwise imposed by law. If you wish to request additional restrictions, the Facility requires that your request be in writing. A request form for additional restrictions on the use and disclosure of your personal information is available from the Facility's Privacy Officer.

The Facility is not required to agree to your request for additional restrictions on the use of personal information. If the Facility does agree to the requested restriction, the Facility is bound by the restriction for as long as the agreement is in effect. The Facility may cancel the agreement for additional restrictions either with or without your consent. If you do not agree to cancel the agreement for restrictions, the Facility must continue to honor the agreement with respect to any information received by the Facility prior to the cancellation.

B. Right to Receive Alternative Communications.

You have the right to request to receive communications regarding personal information by an alternative method or at an alternative location. Alternative methods of communicating health information may include communicating information by fax or email rather than mailing information. Providing information at an alternative location may include sending information to a post office box or work address rather than a facility address. If communication of personal health information is requested via e-mail a "Waiver of Responsibility for Electronic Communication" must be signed. This form is obtained through your Privacy Officer.

The Facility must honor any reasonable request for an alternative means of communicating health information. Ordinarily, a request is reasonable if the Facility has the ability to communicate the information by the means requested and to verify the location to which the information is to be sent.

The Facility will make reasonable efforts to accommodate a request to communicate personal information through a specific method. For example, the Facility generally will be able to mail paper copies of personal records to an alternative address such as a post office box or work address. At the same time, the Facility does not currently have the capability of readily transferring many paper records into electronic computer files. Therefore, the Facility may not be able to honor a request to communicate information through email.

The Facility also may need to verify that contact information is correct before sending personal information to an alternative location. For example, the Facility can accommodate a request by you to send information by fax. Before sending the information, however, the Facility may require verification that the fax number is correct and that only you or another individual authorized by you to receive the information will have access to the fax transmission.

The Facility requires that requests to receive communications by an alternative method or an alternative location be made in writing. Please submit your written request, including type of alternative means of communication and/ or location to the Privacy Officer.

C. Right to Access and Copy Records.

You have the right to access and receive copies of your records that are maintained by the Facility. A request to access or copy medical records must be in writing and it must be signed and dated by the resident or legal representative within 60 days of the date the request is submitted to the Facility. You or your authorized representative may access the medical record within 24 hours of receiving the request, excluding weekends and holidays. Copies will be provided within two (2) working days, excluding weekends and holidays. If you request to have copies made you will be charged a reasonable fee. The written request should specify whether the records are to be sent to you, your physician, an authorized representative, or if the records are to be held at the Facility.

The Facility is not required to provide access or copies of medical records to you if the Facility determines that providing such access would endanger either the health or safety of yourself or others. In that situation, the Facility is required to provide a copy of the records to a physician of your choice

Please contact the Health Information Management Department for assistance.

D. Right to Request Amendments.

You have the right to request that amendments be made to your personal information. The Facility may deny a request to amend resident information if the record in question was not created by the Facility, is not part of the records maintained by the Facility, is not a record that the resident is entitled to inspect or copy, or if the record is accurate and complete.

A request to amend personal information must be made in writing on the form specified by the Facility. Please contact your Privacy Officer.

Within sixty (60) days of receiving a request to amend personal information, the Facility will notify you whether the amendment has been accepted or denied. If the Facility is unable to act within sixty (60) days of receiving a request, the Facility will provide written notice to you that it is taking a one time thirty (30) day extension.

If the Facility accepts an amendment, the Facility will notify you and make appropriate changes to its own records. In addition, the Facility will make reasonable efforts to notify others, including other health care providers and business associates of the Facility, who have received the records in question and would be affected by the amendment.

If the Facility denies the request for an amendment, the Facility will notify you of the basis for the denial as well as your right to challenge the denial.

E. Right to Request an Accounting of Disclosures of Information.

You have the right to receive an accounting of disclosures of your personal health information that the Facility has made. You may request an accounting of disclosures made during any period up to and including the past six years. The Facility is not required to track disclosures made prior to April 14, 2003.

The Facility is not required to track disclosures of information that are made for the following purposes:

Providing treatment, obtaining payment and carrying out health care operations
Disclosures to an individual of the individual's own information
Disclosures made from the Facility's resident directory or to persons involved with an individual's care
Disclosures made for national security or intelligence purposes
Disclosures made to a correctional institution or law enforcement official
Disclosures that occurred prior to April 14, 2003

At the request of a health oversight or law enforcement agency, the Facility may be required to temporarily suspend your right to receive an accounting of disclosures made to such agency. In order for the suspension to take affect, the agency must notify the Facility that providing an accounting to the resident is likely to interfere with the agency's activities. The agency must also specify the time period during which the suspension will apply.

The Facility will provide you with an accounting of disclosures of personal health information within sixty (60) days of receipt of a written request for the accounting. If the Facility is unable to comply within sixty (60) days, the Facility will provide you with a written notice that the Facility is taking a one-time thirty (30) day extension and also explaining the reasons for the delay.

You are entitled to one (1) accounting within any twelve (12) month period free of charge. If you request a second accounting within the same twelve month period, the Facility reserves the right to charge a reasonable cost based fee for providing the accounting

Please contact your Privacy Officer to request an accounting of disclosures of your personal information.

VIII. Duties and Obligations of the Facility.

The Facility is required by law to maintain the privacy of each resident's protected health information. The Facility is also required to provide each resident with notice of the Facility's legal duties and privacy practices with respect to health information.

The Facility is required to abide by the terms of the Notice of Privacy Practices currently in effect.

The Facility reserves the right to change the terms of its Notice of Privacy Practices and to make the new Notice provisions effective for all health information maintained by the Facility. If the Facility revises its Notice of Privacy Practices, a revised Notice will be posted on the bulletin board at the Facility. A copy of the revised notice will be available after the effective date of the changes, upon request.

IX. Complaint Procedures

If you believe the Facility has violated your privacy rights, you may file a complaint with us. These complaints must be filed in writing on a form provided by the Facility. The complaint form may be obtained from the Facility's Privacy Officer. You may also call the corporate hotline at 1-877-218-0220 to leave a message for the Corporate Privacy Officer. You may also file a complaint with the secretary of the federal Department of Health and Human Services. The Facility will not retaliate against any individual in any way for filing a complaint regarding the potential violation of the privacy rights of any current or former resident.

X. Contact Information.

The Facility has designated a Privacy Official who is responsible for developing and implementing Privacy policies and practices under applicable State and federal laws. Any comments or questions regarding the Facility's Privacy practices may be directed to the Privacy Officer.

XI. Effective Date.

The Facility shall abide by the terms of this Notice of Privacy Practices effective as of the 14th day of April 2003.

Information:

July 26th, 2010 Fox Meadow Country Club, Medina, Ohio to benefit Alzheimer's and Dementia Care Services.

For additional information on golfing or sponsorship opportunities for the July 26 event, call or email Glenn Beaver at 440-257-2027 or Ken Marsenburg at 888-248-2664.

September 13th, 2010 Greene Country Club to benefit Pathways Center for Alzheimer's Care.

For additional information on golfing or sponsorship opportunities for the Sept. 13 event, call or email Ken Marsenburg at 888-248-2664.