GENERAL INFORMATION:  When you are admitted, receive treatment or diagnostic services at this Facility a record of visits/services is made.  This record generally will include a history, physical, consultations, assessment by nursing, social services, dietary, diagnostic reports, such as x-ray and laboratory results, the Minimum Data Set, medications, treatments, care plan/plan of care, authorizations, consents, progress notes by the physician, nursing, social services and others involved in treatment services.  This information is included in your health record either manual and/or computerized and is used as a:

*   Source for documenting assessment, planning care and treatment, recording informed consent, recording progress, ongoing assessment of health status/progress/needs

*   Means of communicating among health professionals who evaluate you and/or provide care and treatment; copies are provided for continuity of care to consultants, hospitals, emergency room or another Health Facility where you might be transferred

*   Source to support billing for services and to meet the requirements of third party     payers

*   Legal document supporting the care, services and treatment provided

*   A resource during surveys by the state, federal and other review agencies

*   A source for Facility planning and marketing

*   A tool with which we can assess and continually work to improve care

*   A source to be used by students and a tool in educating health professionals


Understanding what is in your record and how your health information is used will assist you to:  ENSURE ACCURACY, BETTER UNDERSTAND who, what, when, where and why others may need access to your health information, MAKE INFORMED DECISIONS when authorizing disclosure to others.


YOUR RIGHTS:  The health record is the physical property of the Facility that compiled it. The information belongs to you.  YOU HAVE THE RIGHT TO:

*         Request restriction on certain uses and disclosures of your information provided by 45CFR 164.522

*         Inspect and copy your health record as provided for in 45 CFR 164.524

*         Amend your health record as provided in 45 CFR 164.528

*         Request alternate means of communication to obtain your health information

            45 CFR 164.522(b)

*         Request an accounting of disclosures of Protected Health Information

            45 CFR 164.528

*         Request receipt of the notice electronically and/or to obtain a paper copy of the notice 164.520(b)(1)(iv)(f)           

*         Revoke authorization to use or disclose health information except to the extent that action has already been taken 45 CFR 164.508(b)(5)




*         Report a problem  - or if you have a question, or desire additional information, you may contact Alger L. Brion at (626 ) 963-5955 or if you are not satisfied, contact:  Barbara Dube at (626)963-5955.


*         File a complaint if you think your privacy rights have been violated.  If you are not satisfied with the response to your concern, you may file a written or oral complaint with the Administrator, Ms. Barbara Dube with the address of 435 E. Gladstone St. Glendora, CA 91740.


*         You are also notified that you may file a complaint with the Secretary of Health and Human Services, Office for Civil Rights:


                                    Region IX

                                    U.S. Department of Health and Human Services

                                    50 United Nations Plaza – Room 322

                                    San Francisco, CA 94102

                                    Voice Mail (415) 437-8310

                                    Fax # (415) 437-8329

                                    TDD # (415) 437-8311

                                    Email Address HHS.Mail@hhs.gov





The Facility is responsible to:

*         Maintain the privacy of your health information, to use and disclose information only with your authorization, unless there are exceptions described in this notice or otherwise allowed by related laws, rules and regulations

*         Provide you with a notice as to our legal duties and privacy practices with respect to information we collect, maintain, use, and disclose about you

*         Abide by this notice

*         Provide any amendment record along with other documents when information is disclosed

*         Notify you if we are unable to agree to requested restriction/s

*         Accommodate reasonable requests you may have to communicate health information by alternate means or at alternative locations

*         Use or disclose your health information as required for statistical and funding purposes by the Offices of Statewide Health Planning and Development, the Centers for Medicare and Medicaid Services (CMS) and to the State Medicaid (Medi-Cal) system


The Facility reserves the right to change our privacy practices and to make new practices known to you through our routine methods of communications to the latest address/contact provided.




Your health information will be used for the following:


We will use your information for treatment.  Information obtained by the physician/s, nursing, social, administrative staff or other providers of service will be recorded in your manual and/or computerized record.  This information is used to plan your treatment and services as well as to document progress, events, plans of care, observations and evaluation of care and treatment, information for consultants, diagnostic services or for other providers on transfer to another Facility or other Health Facility.


We will use your health information for payment.  A bill may be sent to a third party such as Medicare, MediCal (Medicaid), Health Maintenance Organizations (HMO), and Insurance Companies or to you.  At least some health information may be provided to the payee that identifies your demographic information, the diagnosis and additional health information to support the billing.


We will use your health information for health care operations.


The Facility and Corporation (as applicable) and staff will use the health/medical record information as needed to carry out the regular operations of the Facility and the respective clinical needs of the treatment staff including the

*         Collecting and reporting to the Office of Statewide Health Planning and Development

*         Use for specific quality assurance processes, committee meetings, on-site reviews for management, internal surveys quality assurance processes and reviews

*         Health record information needed for administrative reporting usually for internal Facility use and/or the Corporation.  Uses of this information may or may not be specific to a patient’s name, i.e., collecting information regarding incidents, trending information for management purposes both at the Facility and Corporate level.


Business Associates:  The Facility may use outside providers for some of the services that we provide through contracts/agreements.  Some examples of these services are the use of specialty consultants; i.e., cardiology, radiology, etc., certain diagnostic tests that are not carried out by the Facility, or consultant educators who may use the specific information to carry out training for the Facility staff.


Patient Location:  Patient location will be provided (unless there is an opposing designation in writing) to those individuals who are determined to be legally authorized representative to obtain the information, responsible party; emergency contact, and in case of conservatorship application, the attorney representing the client.


Notification and Communication:  The Facility may use or disclose health information to notify or assist in notifying representatives as identified as a responsible party/emergency contact.  The latest available address will be utilized.  It is understood the information may be provided to you for appointments, results of tests, general information that would not be confidential via telephone, including voice mail message, email, fax, and written.  The Facility may notify the responsible representatives of the appointments, special meetings to discuss care and treatment, at other times related to the condition/status of the patient. The Facility or the Corporation is not responsible for assuring the information is retained private once it is provided through agreed upon communication methods or when submitted to the name/s of the responsible party/emergency contact. 


Research:  Disclosure of health information for the purposes of research shall only be made after documented approval for the research.  Names of the individual will not be included unless there is a specific authorization.


Funeral Directors and Coroner’s Office:  In the event it is necessary we may disclose the health information to funeral directors and coroner’s office consistent with applicable laws as required for them to carry out their duties.


Food and Drug Administration, Public Health and other required reporting:  We may disclose health information to the extent that is required by law and in the best interest of the client and the requirements of the requesting agency. 


Workers Compensation and Employee Actions:  Information may be disclosed to the extent only as required to carry out the required activities.  The privacy of the resident/patient will be protected within the legal parameters of State.


Law Enforcement:  Disclosure of health information will be provided to the extent necessary to carry out the health and safety of the individual, i.e., general description of the person applicable health condition, special marks, clothing type, other identification data, and information as required by law based on the situation.



Effective date: APRIL 14, 2003








By signing this acknowledgement below, the Resident, and/or Legal Representative, Family Member, Agent, and/or Responsible Party, if any, and as appropriate, acknowledges that he or she has been informed about how Resident’s Medical Information may be used and disclosed or how the Resident can get access to this information, orally and in writing, in a language that he or she understands.



Time : ______________________    __________________________________________




Date: _______________________    __________________________________________

                                                            Legal Representative (if any)



                                                            Family Member (if any)



                                                            Agent (if any)



____________________________    __________________________________________

Facility Witness (if Necessary)       Responsible Party (if any)