ARBUTUS PARK MANOR
207 OTTAWA STREET
JOHNSTOWN, PA 15904
(814) 266-8621

EFFECTIVE DATE: JULY 16, 2003

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

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

OUR FACILITY'S POLICY REGARDING YOUR HEALTH INFORMATION
We are committed to preserving the privacy and confidentiality of your health information created and/or maintained at our facility. Certain state and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our facility and others outside of our facility that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills and any other use required by law. We may use or disclose your health information in any of the following ways:
1. For purposes of treatment, payment or health care operations
2. For purposes other than treatment, payment or health care operations
3. For use in our facility directory or to discuss your health condition with family or friends who are involved in your care
4. As permitted by law
5. As required by law

USES OR DISCLOSURES MADE PURSUANT TO YOUR WRITTEN CONSENT TREATMENT
We may use your health information to provide you with health care treatment and services. We may disclose your health information to doctors, nurses, nursing assistants, pharmacists, technicians, nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care. For example, your protected health may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT
We may use or disclose your health information so that we may bill and collect payment from you, an insurance company, or other third party for the health care services you receive at our facility. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval for the services or to determine whether your health plan will cover the treatment.

HEALTH CARE OPERATIONS
We may use or disclose, as needed, your protected health information to perform certain functions within our facility. These uses or disclosures are necessary to operate our facility and to make sure that our residents receive quality care. For example, we may use your health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may combine health information about many of our residents to determine whether certain services are effective or whether additional services should be provided. We may disclose your health information to physicians, nurses, nursing assistants, pharmacists, rehabilitation therapy specialists, technicians, nursing students and other personnel for review and learning purposes. We also may combine health information with information from other health care providers or facilities to compare how we are doing and see where we can make improvements in the care and services offered to our residents. We may remove information that identifies you from this set of health information so that others may use the information to study health care and health care delivery without learning the specific identities of our residents. We may use a limited amount of your health information for purposes of contacting you to raise money for our facility and its operations.

USES OR DISCLOSURES MADE PURSUANT TO YOUR WRITTEN AUTHORIZATION
We may use or disclose your health information, pursuant to your written authorization, for purposes other than treatment, payment of health care operations and for purposes, which are not permitted or required by law. You have a right to revoke a written authorization at any time as long as your revocation is provided to us in writing. If you revoke your written authorization, we will no longer use or disclose your health information for the purposes identified in the authorization. You understand that we are unable to retrieve any disclosures, which we may have made pursuant to your authorization prior to its revocation. Examples of uses or disclosures that may require your written authorization include the following:
1. A request to provide certain health information to a pharmaceutical company for purposes of marketing.
2. A request to provide your health information to an attorney for use in a civil litigation claim.

USES OR DISCLOSURES MADE PURSUANT TO YOUR VERBAL AGREEMENT
We may use or disclose your health information, pursuant to your verbal agreement, for purposes of including you in our facility directory or for purposes of releasing information to persons involved in your care as described below.
1. Facility directory. We may use or disclose certain limited health information about you in our facility directory while you are a resident at our facility. This information may include your name, your assigned unit and room number, your religious affiliation and a general description of your condition. Your religious affiliation may be given to a member of the clergy. The directory information, except for the religious affiliation, may be given to people who ask for you by name.
2. Individuals involved in your care. We may disclose your health information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We also may disclose your health information to a person or organization assisting in disaster relief efforts for the purpose of notifying your family or friends involved in your care about your condition, status and location.

USES OR DISCLOSURES PERMITTED BY LAW
Certain state and federal laws and regulations either require or permit us to make certain uses or disclosures or your health information without your permission. These uses or disclosures are generally made to meet public health reporting obligations or to ensure the health and safety of the public at large.
1. Public health activities. To report deaths. To report suspected or actual abuse, neglect or violence involving an adult. To report adverse reactions to medications or problems with health care products. To notify individuals of product recalls. To notify an individual who may have been exposed to a disease or may be at risk for spreading or contracting a disease or condition.
2. Health oversight activities. We may use or disclose your health information for purposes of audits, investigations, inspections, or licensure and certification surveys. These activities are necessary for the government to monitor the persons or organizations that provide health care to individuals and to ensure compliance with applicable state and federal laws and regulations.
3. Judicial or administrative proceedings. We may use or disclose your health information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute.
4. Worker's compensation. We may use or disclose your health information to worker's compensation programs when your health condition arises out of a work related illness or injury.
5. Law enforcement official. We may use or disclose your health information in response to a request received from a law enforcement official: In response to a court order, warrant, summons or similar process. To identify or locate a missing person. To report a death that we believe may be the result of criminal conduct. To report criminal conduct at our facility. In emergency situations, to report a crime.
Coroners, medical examiners, or funeral directors. We may use or disclose your health information for the purpose of identifying a deceased individual or to determine the cause of death or for the purpose of carrying out his/her necessary activities.
6. Organ procurement organizations or. tissue banks. If you are an organ donor, we may use or disclose your health information to organizations that handle organ procurement, transplantation, or tissue banking.
7. Research. We may use or disclose your health information for research purposes if approved through the special approval process.
8. To avert a serious threat to health or safety. We may use or disclose your health information when necessary to prevent a serious threat to the health or safety of you or other individuals.
9. Military and veterans. If you were a member of the armed forces, we may use or disclose your health information as required by military command authorities.
10. National security and intelligence activities. We may use or disclose your health information for purposes of national security as authorized by law.
11. Uses or disclosures required by law. We may use or disclosure your health information where such uses or disclosures are required by federal, state or local law.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION.
You have the following rights regarding your health information, which we create and/or maintain.
1. 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. To inspect and copy your health information, you must submit a request in writing. Under federal law, however, you may not inspect or copy the following records: Psycotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
2. Right to request an amendment. You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and must state the specific restriction requested and to whom you want the restriction to apply. We 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, we may deny your request if you ask us to amend information that was not created by us, is not part of the health information kept by or for our facility, or is not part of the information which you would be permitted to inspect and copy, or if the information is accurate and complete.
3. Right to accounting of disclosures. You have the right to request an accounting of the disclosures which we have made of your health information. This accounting will not include disclosures or health information that we made for purposes of treatment, payment, or health care operations. You must submit your request in writing. Your request must state a time period which may not be longer than (6) six years prior to the date of your request and may not include dates before April 14, 2003.
4. Right to request restrictions. You have the right to request a restriction or limitation on the health 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 health information we disclose about you to someone, such as a fan1ily member or friend, who is involved in your care or the payment of your care. 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 emergency treatment to you. You must request restrictions in writing. You must state what information you want to limit, whether you want to limit our use, disclosure or both; and to whom you want the limits to apply.
5. Right to request confidential communication. Right to request confidential communications. You have the right to request that we communicate with you about your health care in a certain way or at a certain location. To request confidential communication, you must make the request in writing. We will not ask you the reason for your request. Your request must be specify how or where you wish to be contacted.
6. Right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. You may obtain a copy of this notice at our Web Site: www.arbutusparkmanor.com

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our facility or with the secretary of the Department of Health and Human Services. To file a complaint with our facility, contact facility administrator. All complaints must be submitted in writing. You will NOT be penalized for filing a complaint. Arbutus Park Manor reserves the right, for itself, to change the terms of its Notice of Privacy Information for Protected Health Information at any time. If Arbutus Park Manor does change the terms of its Notice of Privacy Practices, Resident may obtain a copy of the revised policy by requesting it. Families of residents may obtain a copy of this Policy by contacting Arbutus Park Manor in writing or by phone. This Policy may also be found at the Arbutus Park Manor website at: www.arbutusparkmanor.com