THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1.  Eben Ezer Lutheran Care Center is permitted to use and disclose protected health information for treatment, payment, and healthcare operations, including but not limited to the following examples:
• For treatment-e.g., sending a fax to a physician regarding a resident’s condition
• For payment-e.g., sending information about a resident to Medicare in order to obtain payment for services.
• For healthcare operations-e.g., sharing information about a resident at a care conference

2.  Eben Ezer Lutheran Care Center is permitted or required, under specific circumstances, to use or disclose protected health information without the individual’s written authorization. This occurs when Eben Ezer is asked to provide information to a regulatory agency.

3.  Other uses and disclosures will be made only with the individual’s written authorization, and the individual may revoke such authorization.

4.  Eben Ezer Lutheran Care Center intends to engage in the following activities:
• Eben Ezer Lutheran Care Center may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual or patient.
• Eben Ezer Lutheran Care Center may contact the individual/patient or his/her family to raise funds for Eben Ezer.

5.  The individual has the following rights regarding protected health information:
• The right to request restrictions on certain uses and disclosures of protected health information. Eben Ezer is not required to agree to a requested restriction however.
• The right to receive confidential communications of protected health information , as applicable.
• The right to inspect and copy protected health information, as provided in the Privacy Regulation.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the notice electronically.

6.  Eben Ezer Lutheran Care Center is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.

7.  Eben Ezer Lutheran Care Center is required to abide by the terms of the Notice currently in effect.

8.  Eben Ezer Lutheran Care Center reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.

9.  Eben Ezer Lutheran Care Center will provide individuals or patients with a revised Notice in writing.

10.  Individuals may complain to Eben Ezer Lutheran Care Center, the Colorado Department of Public Health and Environment, and the Secretary of the department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A brief description of how the individual may file a compliant follows:
• The individual will contact the Eben Ezer Social Services Department or the other two agencies listed below and report the complaint.
• The complaint will be documented in writing.

11.  Eben Ezer Lutheran Care Center’s contact office for matters relating to complaints is:

Social Services Department
970-842-2861
Eben Ezer Lutheran Care Center
122 Hospital Road
Brush, CO 80723

Colorado Department of Public Health and Environment
Health Facilities Division
4300 Cherry Creek Drive South
Denver, CO 80246-1530
303-692-2800

The Department of Health and Human Services
Secretary
200 Independence Ave., S.W.
Washington, D.C. 20201