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Lutheran Village at MILLER’S GRANT
PRIVACY NOTICE
PLEASE NOTE: WE ARE REQUIRED BY FEDERAL LAW TO PROVIDE YOU WITH A COPY OF OUR PRIVACY POLICY. PROTECTING YOUR PRIVACY RELATING TO USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION At Lutheran Village at Miller’s Grant we are committed to safeguarding your private health information and maintaining your privacy. Lutheran Village at Millers Grant is providing you this policy notice to help you understand how we handle health information that we collect and may disclose. This notice tells you how you can limit our disclosure of your health information. Patient Rights for Understanding and Controlling the Utilization of Health Information: Lutheran Village at Miller’s Grant will provide a written explanation of how healthcare provider can use, keep and disclose patient healthcare information (this privacy notice). Lutheran Village at Miller’s Grant will ensure patient access to his/her medical record(s). Lutheran Village at Miller’s Grant, will obtain consent before healthcare information is shared for treatments, payment and other healthcare operation purposes. Lutheran Village at Miller’s Grant will provide information for recourse for privacy protection violations. Patients have a right to request electronic copies of their records if their health care provider maintains records in electronic form. Patients also have the right to restrict the disclosure of some of their protected health information to a health plan when the patient has paid out of pocket in full for their care. Our Policies and Procedures to Protect Your Health Information: At Lutheran Village at Miller’s Grant we understand the importance of protecting your health information. That’s why we protect the information we collect about you by maintaining, physical, electronic, and procedural safeguards that meet or exceed applicable law. Within Lutheran Village at Miller’s Grant we educate our employees about the importance of confidentiality and privacy, and we train them in related policies and procedures. We also take appropriate disciplinary measures whenever necessary to enforce these rules. Information: Lutheran Village at Miller’s Grant is responsible for providing rehabilitation services that enable you to meet your optimal functional level. In order to provide you with the appropriate rehabilitation, Lutheran Village at Miller’s Grant , needs to obtain information that enables us to provide you with responsive, rehabilitation services. Your information comes to us from a variety of sources: You provide some of the information to us at the time of setting your appointment with the evaluating therapist. You provide most of your information to us at the time of your first appointment with us when you are requested to fill out forms giving, but not limited to, information concerning your name, address, social security number, employer, insurance coverage, health history, medications, etc. Your physician provides us with information concerning your treatment diagnosis when s/he orders a therapy evaluation and treatment for your medical condition. Your insurance company provides verification to us of your insurance coverage. Here is how we put information to use for you: health information allows us to provide you with the appropriate rehabilitation services. Health information and your progress in rehab are shared with your physician to provide comprehensive rehabilitation services to you. Personal and Healthcare information may be shared with your medical insurance company to bill for your rehab services. Lutheran Village at Miller’s Grant works hard to maintain complete and accurate information about you and your health services. If you ever believe that our records contain inaccurate or incomplete information about you, please let us know immediately, so we may correct any inaccuracies. Disclosure of Protected Health Information: Patient health information will be used or disclosed for purposes of treatment, payment, and operations. Patient health information will be limited to the minimum necessary for the purpose of disclosure. Authorizations for disclosure of non-routine patient information will meet standards that ensure the authorization is informed and voluntary. Lutheran Village at Miller’s Grant may disclose health information without your authorization, including the following: Quality assurance activities, Public Health, Research, Judicial or administrative proceedings, Limited law enforcement activities, Emergency circumstances, Identification of a deceased person or cause of death, Facility patient directories, National defense or security. Marketing: Prior written authorization will be obtained from an individual to use his/ her protected health information for marketing purposes. HIPAA regulations strengthen the limitations on the use and disclosure of protected health information (PHI) by covered entities and business associates for marketing and fundraising purposes. The new HIPAA regulations also prohibit the sale of PHI by covered entities or business associates without the consent of the patient.
I, the Undersigned, hereby voluntarily authorize Provider to administer such outpatient therapy treatment(s) to the Client that in the opinion of the physician and consulting allied health personnel is/are necessary or appropriate. It has been explained to me that therapy is not an exact science and no guarantee has been made as a result of any treatment administered. I, the Undersigned, understand that the rehabilitation process, by its very nature, involves certain inherent and unavoidable risks, including falls and other similar injuries, and that the only alternative to entirely avoiding these risks would be to forego rehabilitation altogether. I, therefore, acknowledge that falls and other similar injuries are an inherent risk of the rehabilitation process and accept that risk. I, the Undersigned, hereby certify that all information provided to the Provider by the Undersigned or Client is true and accurate, including any information in connection with applying for payment under Title XVIII of the Social Security Act. I, the Undersigned, hereby authorize Provider to disclose any information, furnished to Provider or obtained by Provider in connection with Patient’s treatment (including, but not limited to, information concerning a related Medicare claim) to any physician, governmental agency (including, but not limited to, the Social Security Administration, its fiscal intermediaries or carriers), insurance company or health care facility requesting such information. I, the Undersigned, hereby assign to Provider all Medicare benefits and Medicaid benefits to which Client may be entitled for any Therapy Services rendered by Provider. I, the Undersigned, hereby authorize and direct Provider to apply and file for all such benefits on behalf of Client. I, the Undersigned, hereby assign to Provider all private medical insurance benefits (primary and secondary, including Medicare Gap providers) or other benefits to which Client may be entitled for any Therapy Services rendered by Provider. I, the Undersigned, hereby authorize and direct Provider to apply and file for all such benefits on behalf of Client. I, the Undersigned, agree that the discretion of payment for Therapy Services is that of the Insurer not that of the Provider and any services not subject to the Insurer’s benefit coverage will be the responsibility of the authorizing parties.
Facility: Lutheran Village at MILLER’S GRANT
Please bring your insurance cards to your visit.
We need a copy of your DNR/MOLST.
If required, we will perform CPR.
Completion of the following information for National Origin, Race/Ethnic Group and Disabilty is voluntary that will not affect your receiving therapy services in any way. In compliance with the Federal government requirements of the Office of Civil rights (OCR), we ask you to complete this information to assist in the collection of data for our civil rights compliance. Thank you.
