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Effective Date: April 14, 2003


If you have any questions about this notice, please contact our Privacy Officer Philip E. Flory, Vice President at (540) 828-2661.

Bridgewater Retirement Community, hereinafter referred to as BRC, understands that health information about you and your health care is personal, and is committed to protecting health information about you. BRC creates a record of the care and services you receive, and needs this record to provide you with quality care and to comply with legal requirements. This notice applies to all of the records of your care generated by BRC, whether made by our personnel, your personal doctor or other appropriate professionals. This notice will tell you about the ways in which BRC may use and disclose health information about you. It also describes your rights to the health information kept about you, and describes the obligations BRC has regarding the use and disclosure of your health information.

BRC is required by law to:
  • make sure that health information that identifies you is kept private;
  • give you this notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the notice that is currently in effect.

The following categories describe different ways that BRC uses and discloses health information. For each category of uses or disclosures BRC will explain what is meant and will try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways BRC is permitted to use and disclose information will fall within one of the categories.

For Treatment. BRC may use health information about you to provide you with health care treatment or services. BRC may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in your care. They may work at BRC, the hospital, or in a doctor's office, lab, pharmacy, or other health care provider to whom you may be referred for consultation. They may use this information to take x-rays, perform lab tests, have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian at the hospital if you have diabetes so that BRC can arrange for appropriate meals. BRC may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

For Payment: BRC may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, your Power of Attorney, an insurance company, or a third party. For example, BRC may need to give your health plan information about you so your health plan will pay us or reimburse you. BRC may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations: BRC may use and disclose health information about you for its operations. These uses and disclosures are necessary to run BRC and make sure that all of our residents receive quality care. For example, BRC may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. BRC may also combine health information about many residents to decide what additional services BRC should offer, what services are not needed, whether certain new treatments are effective, or to compare how BRC is doing with others and to see where BRC can make improvements. BRC may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific residents are.

Fundraising Activities: BRC may disclose health information about you to the Bridgewater HealthCare Foundation, Inc. so that the Foundation may contact you in raising funds for our not-for-profit activities. We will only release contact information, such as your name, address, and phone number, and the dates related to your stay at BRC. Please let us know if you do not want us to contact you for such fundraising efforts.

As Required By Law. BRC will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. BRC may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, BRC may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable.

Workers' Compensation. BRC may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. BRC may disclose health information about you for public health activities. These activities generally include the following:
  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report child abuse or neglect;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person or organization required to receive information on FDA-regulated products;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if BRC believes a resident has been the victim of abuse, neglect, or domestic violence. BRC will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. BRC may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, BRC may disclose health information about you in response to a court or administrative order. BRC may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. BRC may release health information if asked to do so by a law enforcement official:
in reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime;
in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person:

  • Name and address
  • Date of birth or place of birth
  • Social security number
  • Blood type or rh factor
  • Type of injury
  • Date and time of treatment and/or death, if applicable
  • A description of distinguishing physical characteristics
  • about the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, BRC is unable to obtain the person's agreement;
  • about a death BRC believes may be the result of criminal conduct;
  • about criminal conduct at BRC; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Health Examiners and Funeral Directors. BRC may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. BRC may also release health information about residents to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. BRC may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. BRC may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

You have the following rights regarding health information BRC maintains about you:

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. This does not include psychotherapy notes. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer Philip E. Flory, Vice President. If you request a copy of the information, BRC may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

BRC may deny your request to inspect and copy in certain very limited circumstances. If the Privacy Officer denies your request for access to your health information, you may request that the denial be reviewed. The President of BRC will review your request and the denial. BRC will comply with the outcome of the review.

Right to Amend. If you feel that health information BRC has about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as BRC keeps the information. To request an amendment, your request must be made in writing, submitted to our Privacy Officer Philip E. Flory, Vice President, and must be contained on one page of paper legibly handwritten or typed. In addition, you must provide a reason that supports your request for an amendment.

BRC may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, BRC may deny your request if you ask us to amend information that:
was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

  • is not part of the health information kept by or for BRC;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

Any amendment BRC makes to your health information will be disclosed to those with whom BRC agrees to disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information BRC has made, except for uses and disclosures for treatment, payment, and health care operations, as previously described. To request this list of disclosures, you must submit your request in writing to our Privacy Officer Philip E. Flory, Vice President. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, BRC may charge you for the costs of providing the list. BRC will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. BRC will mail you a list of disclosures in paper form within 30 days of your request. If BRC is unable to supply the list within the 30 day time period, you will be notified by what date BRC can supply the list. This date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information BRC uses or discloses about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information BRC discloses about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that BRC restrict a specified nurse from use of your information, or that BRC not disclose information to your spouse about a surgery you had. BRC is not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or if we believe it will negatively impact the care BRC may provide you. If BRC does agree, BRC will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to our Privacy Officer Philip E. Flory, Vice President. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

Right to Request Confidential Communications. You have the right to request that BRC communicate with you about health matters in a certain way or at a certain location. BRC will request that you, or your responsible party, sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name, and indicate the date. This acknowledgement will be filed with your records.

To request confidential communications, you must make your request in writing to our Privacy Officer Philip E. Flory, Vice President. BRC will not ask you the reason for your request. BRC will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from our Privacy Officer Philip E. Flory, Vice President.
You may also obtain a copy of this notice either from our website, www.bridgewaterretirement.org, or by requesting a copy of this notice be sent through electronic mail to philflory@bridgewaterretirement.org. If BRC knows that the electronic message has failed to be delivered, a paper copy of the notice will be provided. Even if you have received a notice electronically, you still retain the right to receive a paper copy upon request.

BRC reserves the right to change this notice. BRC reserves the right to make the revised or changed notice effective for health information BRC already has about you as well as any information BRC receives in the future. BRC will keep a copy of the current notice posted. The notice will state the effective date on the first page. In addition, each time you are admitted to BRC, you be offered a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer Philip E. Flory, Vice President. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, BRC will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that BRC is unable to take back any disclosures already made with your permission, and that BRC is required to retain records of the care provided to you.
Acknowledgement of Receipt of this Notice