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FACILfT Y RESPONSIBILITY <br /> The facility is responsible to: <br /> • Maintain the privacy of your health information,to use and disclose information only with <br /> your authorization,unless there are exceptions described in this notice or otherwise <br /> allowed by related laws,rules and regulations. <br /> ® Provide you with a notice as to our legal duties and privacy praeticeswith respect to <br /> information we collect,maintain,use, and disclose about you. <br /> ® Abide by this-notice <br /> i Provide any amendment record along with other documents when information is disclosed <br /> • Notify you if we are unable to agree to requested restrictions) . <br /> s Accommodate reasonable requests you may have to communicate health information by <br /> alternate means of to alternate locations <br /> Use or disclose your health information as required for statistical and funding purRoses by <br /> the O€fices.to Statewide Health Planning and Developments the Centers for Medicare and <br /> Medicaid Services CMS) <br /> The facility reserves the right to change our privacy practices and to make new Practices known <br /> to you through our routine methods of communications to the latest address/contact provided. <br /> EXA14PIM OF DISCLOSDJU FOR T REATMEIT1',PAYMENT AND HEALTH OFERATIONS - <br /> Your health information will be used for the following: <br /> We will use your information for treatment. Information obtained by the physician(s),nursing, <br /> I <br /> ial,administrative staff or other providers of service will be recorded in your record- This <br /> ,ormation is used to plan your treatment and services as well as to document progress, events, <br /> plans of care,observations and evaluation of care and treatment,information for consultants, <br /> diagnostic services or for other providers on traiisfer to another Facility or Hospital. We will <br /> our Healt�i Priformafion for payment. A bill may be sent to A third party such as Medicare. <br /> Health Maintenance Organizations(HMO),and Insurance Companies or to you. At least some <br /> health information may be provided to the payee that ideatifies.your demographic information, <br /> the diagnoses and additional health information to support the billing <br /> We will use your health information for health care operations. <br /> The facility and Corporation and staff will use the health/medzcal record information as needed to <br /> carry out the regular operations of the Facility and the respective clinical needs of the treatment <br /> staff including the <br /> • Collecting and reporting to the Office of Statewide Health Planning&development <br /> • Ilse for specific quality assurance processes, committee meetings, on-site reviews for <br /> management,internal survey's <br /> • Health record information needed for administrative reporting usually for internal Facility <br /> use and/or the Corporation. Uses of this information may or may not be specific to a <br /> patient's name i.e.collecting information regarding incidents and trending information. <br /> Business Associates: The Facility may use outside providers for some of the services that we <br /> -rovide through contracts/agreements. Some examples of these services are the use of specialty <br /> isultants; i.e. psychiatry,podiatry, radiology, etc-, certain diagnostic tests that are not carried <br /> ,it by the Facility, or consultant educators who many use the specific information to carry out <br /> training for the Facility staff. <br />