If you have any questions about this notice, please contact the Community’s Executive Director at 928-440-2350.

Section A: Summary Notice

Your medical information is personal. The Community is required by law to maintain the privacy of your medical information and abide by the terms of this notice. We reserve the right to change the terms of this notice. A current notice will be prominently displayed at our Community and given to you if you ask.

We use and disclose your medical information to help with your treatment, payment for your treatment and our health care operations, and in other ways permitted or required by law. When the law requires us to get your permission before we release your information to another organization or person, we do so as described in the more detailed portions of this notice.

This notice will tell you about the ways in which we may use and disclose medical information about you. You have several other rights related to your privacy. Those rights, and how you may exercise them, are described in the more detailed portions of this notice.

Section B: How We May Use and Disclose Medical Information About You

“Medical information” is information about you that relates to your past, present or future physical or mental health, payment for health care services, or the provision of health care services. Medical information includes information the Community receives from you on applications and other forms, including demographic information such as your name, address and phone number, as well as your social security number, age, date of birth, dependents and health history. It also includes the information the Community creates, receives, or maintains related to the health care you receive while you are at the Community.

We permit access to your medical information by our staff and others only to the extent reasonably necessary to conduct or support treatment, payment or other health care operations, or as otherwise authorized by you or the law. We maintain physical, electronic and administrative safeguards designed to protect your personal information and prevent unauthorized access. We never sell your medical information to anyone. Examples of how we use and disclose your medical information include the following. Not all uses and disclosures are listed below, however, these examples describe the types of uses and disclosures that are permitted.

• Treatment – We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, or other personnel of the Community who are involved in taking care of you at the Community. For example, a doctor treating you for a broken hip 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 if you have diabetes so that we can arrange for appropriate meals. Different departments of the Community also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, and x-rays. We also may disclose medical information about you to people outside the Community who may be involved in your medical care after you leave the Community, such as family members, clergy, or others we use to provide services that are part of your care.
• Payment – We may use and disclose medical information about you so that the treatment and services you receive at the Community may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about care you received at the Community so your health plan will pay us or reimburse you for the care. We 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. However, if you pay for services out of pocket, you have the right to prohibit us from disclosing your medical information to your insurance company or for our health care operations, unless required by law. However, if such payment is made by your FSA or HSA account, you may not restrict a disclosure to the FSA or HSA necessary to effectuate such payment.
• Health Care Operations – We may use and disclose medical information about you for Community operations. These uses and disclosures are necessary to run the Community and make sure that all of our residents receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Community residents to decide what additional services the Community should offer, what services are not needed, and whether certain new treatments are effective.
• Appointment Reminders – We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Community.
• Treatment Alternatives – We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
• Health-Related Benefits and Services – We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
• Community Directory – We may include certain limited information about you in the Community directory while you are a resident at the Community. This information may include your name, location in the Community, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends, and clergy can visit you in the Community and generally know how you are doing. You have the right to request not to be included in the Community directory.
• Individuals Involved in Your Care or Payment for Your Care – We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the Community. In addition, we may disclose medical 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. You have the right to request that we not give information to certain individuals.
• Research – We may use or share your health information for research, under certain conditions. For example, a research review board must first ensure that researchers will keep your information private. The Community will not use your medical information unless you give us permission in writing or the research review board decides that permission is not needed. You have the right to request not to use your medical information for research purposes.
• As Required By Law – We will disclose medical information about you when required to do so by federal, state, or local law.

Section C: Special Situations

• To Avert a Serious Threat to Health or Safety – We may use and disclose medical 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.
• Organ and Tissue Donation – If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
• Military and Veterans – If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• Workers’ Compensation – We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
• Public Health Risks – We may disclose medical 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 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 we believe a resident has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
• Health Oversight Activities – We may disclose medical 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 oversee the health care system.
• Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical 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 – We may release medical information if asked to do so by a law enforcement official:
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the Community; 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, Medical Examiners and Funeral Directors. – We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about residents of the Community to funeral directors as necessary to carry out their duties.
• National Security and Intelligence Activities. – We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• Marketing and Sale of Medical Information. – Most uses and disclosures of your medical information for marketing purposes or that constitute a sale of your medical information require your authorization. We are prohibited from selling your medical information. You have the right to opt out of receiving any fund-raising communication.
• Psychotherapy Notes. – If we maintain psychotherapy notes, most uses and disclosures of psychotherapy notes require your authorization.

Section D: Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy – You have the right to inspect and copy the medical information that may be used to make decisions about your care. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy medical information in certain circumstances. If you are denied access to medical information, in some cases, you may request that the denial be reviewed.
• Right to Amend – If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. However, we are not required to agree to your suggested change. If we deny your change, you may file a written statement of disagreement with our decision that will be kept with your medical information.
• Right to an Accounting of Disclosures – You have the right to request an “accounting of disclosures,” which is a list of certain disclosures we have made containing medical information about you to nonaffiliated third parties. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list.
• Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
• Right to Request Confidential Communications – You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests.
• Right to a Paper Copy of This Notice – You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
• Right to Opt out of Fundraising Communications – The Community may contact you for fundraising purposes. We will only share contact information and the dates you received services at the Community. You have the right to opt out of receiving fund-raising communications.
• Right to Notice of Unauthorized Release of Unsecured Medical Information – You have the right to be notified by us of any release that we make of your medical information that is otherwise unauthorized either by law or by you.

To exercise the above rights, please contact the following individual to obtain a copy of the relevant form you will need to complete to make your request: Administrator/Executive Director at 1521 N Pine Cliff Drive, Flagstaff, AZ 86001 (928-440-2350).

Section E: Changes To This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the Community. The notice will contain the effective date. In addition, each time you register at or are admitted to the Community for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Section F: Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Community or with the Secretary of the Department of Health and Human Services. To file a complaint with the Community, contact the Administrator/Executive Director at 1521 N Pine Cliff Drive, Flagstaff, AZ 86001. All complaints must be submitted in writing.

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.

Section G: Other Uses of Medical Information

Other uses and disclosures of medical 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 medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.