NOTICE OF PRIVACY PRACTICES

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

Attic Angel Place (“Facility) may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions in the Health Insurance Portability and Accountability Act of 1996. As follows, the Facility has established a policy to guard against unnecessary disclosure of your health information.

1. The Following is a summary of the circumstances and purposes for which your health information may be used and disclosed with written consent, signed upon admission:

To Provide Treatment. Facility may use your health information to provide care to you and may disclose your health information to others who provide care to you, such as your attending physician and other health care professionals. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. The Facility also may disclose your health care information to individuals outside of the Facility involved in your care including designated family members, pharmacists, suppliers of medical equipment and/or other health care professionals.
To Obtain Payment. Facility may include your health information in invoices to collect payment from third parties for the care you may receive from Facility. For example, Facility may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Facility. The Facility also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you.
To Conduct Health Care Operations. Facility may use and disclose health information for its own operations in order to facilitate the function of Facility and as necessary to provide quality care to all of Facility's residents. Health care operations include activities such as:
• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and residents with information about treatment alternatives and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Training of non-health care professionals.
• Accreditation, certification, licensing or credentialing activities.
• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs, including state regulating agencies
• Business planning and development including cost management and planning related analyses and formulary development.
• Business management and general administrative activities of Facility.
• Fundraising for the benefit of Facility and certain marketing activities.
For example: Facility may use your health information to evaluate its staff performance.   Facility may use your health information for quality assurance and process improvement.
For the Facility Directory. Facility may disclose certain information about you including your name, religious affiliation and where you are located in a facility directory while you reside in Facility. Facility may disclose this information to people who ask for you by name. However, religious affiliation will only be disclosed to clergy, activity and staff volunteers who assist in religious activities. If you do not want Facility to include your information in the directory, you must notify Deb Bergen, Director of Admissions and Social Services, at 608-662-8824.
For Fundraising Activities. Facility may use your name, address and telephone number to contact you, your children or a person(s) designated by you, to raise money for the Facility. If you do not want Facility to contact you, your children or designated person(s),  you must notify Beth Richardson, Administrator, in writing, and indicate that you do not wish to be contacted.
For Treatment Alternatives. Facility may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

2. The following is a summary of the circumstances and purposes for which your health information may be used and disclosed without your written consent or authorization.

When Legally Required. Facility will disclose your health information when it is required to do so by any Federal, State or local law.
When There Are Risks to Public Health. Facility may disclose your health information for the following public activities and purposes:
• To prevent or control disease, injury or disability, and to report disease, injury, vital events such as birth or death and to conduct public health surveillance, investigations and interventions.
• To report adverse events, product defects, and to track products or enable product recalls, repairs and replacements, and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
• To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
• To an employer about an individual who is a member of the workforce as legally required.
To Report Abuse, Neglect Or Domestic Violence. Facility is allowed to notify government authorities if Facility believes a resident is the victim of abuse, neglect or domestic violence. Facility will make this disclosure only when specifically required or authorized by law and/or when the resident agrees to the disclosure.
To Conduct Health Oversight Activities. Facility may disclose your health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Facility, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits.
In Connection With Judicial And Administrative Proceedings. As permitted or required by State law, Facility may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, as expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process. This would occur only when Facility makes reasonable efforts to either notify you about the request, or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by State law, Facility may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
To Coroners And Medical Examiners. Facility may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors. Facility may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Facility may disclose your health information prior to and in reasonable anticipation of your death.
For Organ, Eye Or Tissue Donation. Facility may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue, for the purpose of facilitating the donation and transplantation.
For Research Purposes. Facility may, under very select circumstances, use your health information for research. Before Facility discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Facility will always request your written authorization before granting access to your individually identifiable health information.
In the Event of A Serious Threat To Health Or Safety. Facility may, consistent with applicable law and ethical standards of conduct, disclose your health information if Facility, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, Federal regulations authorize Facility to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker's Compensation. Facility may release your health information for worker's compensation or similar programs.

3. Authorization to use or disclose health information.
Other than is stated above, Facility will not disclose your health information other than with your written authorization. If you or your representative authorizes Facility to use or disclose your health information, you may revoke that authorization in writing at any time.

4. Your rights with respect to your health information.
You have the following rights regarding your health information that Facility maintains:
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Facility's disclosure of your health information to someone who is involved in your care or the payment of your care. However, Facility is not required to agree to your request. If you wish to make a request for restrictions, please contact Beth Richardson, Administrator, at 608-662-8822.
Right to Receive Confidential Communications. You have the right to request that Facility communicate with you in a certain way. For example, you may ask that Facility only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Deb Bergen, Director of Admissions and Social Services, at 608-662-8824. Facility will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Beth Richardson, Administrator, at 608-662-8822. If you request a copy of your health information, Facility may charge a reasonable fee for copying and assembling costs associated with your request. Facility will provide access within 24 hours excluding weekends and holidays.
Right to Amend Your Health Information. You or your representative have the right to request that Facility amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Facility. A request for an amendment of records must be made in writing to Beth Richardson, Administrator, at 608-662-8822. Facility may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Facility, if the records you are requesting are not part of Facility's records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Facility, the records containing your health information are accurate and complete.
Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Facility for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to Beth Richardson, Administrator, at 608-662-8822. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years prior to the current date. Facility is required to keep an accounting of disclosures for a period of only six years. Facility will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact Beth Richardson, Administrator, at 608-662-8822. A resident or a resident's representative may also obtain a copy of the current version of Facility's Notice at its Web site, www.atticangel.org .
Right to Lodge a Complaint. You or your representative have the right to express complaints to Facility and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated.
Any complaints to Facility should be made in writing to Beth Richardson, Administrator, Attic Angel Place, 8301 Old Sauk Road, Middleton, WI, 53562. Facility encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

5. Duties of Facility. Facility is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. Facility is required to abide by the terms of this Notice as may be amended from time to time. Facility reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Facility changes its Notice, Facility will provide a copy of the revised Notice to you or your appointed representative.

6. CONTACT PERSON Facility has designated Beth Richardson, Administrator, as its contact person for all issues regarding resident privacy and your rights under the Federal privacy standards. You may contact her by phone at 608-662-8822 or by mail at Attic Angel Place, 8301 Old Sauk Road, Middleton, WI, 53562.

7. EFFECTIVE DATE This Notice is effective April 14, 2003.

8. QUESTIONS REGARDING THIS NOTICE SHOULD BE BE DIRECTED TO Beth Richardson, Administrator and Privacy Officer, at 608-662-8822.