SOVEREIGN HEALTHCARE
NOTICE OF PRIVACY PRACTICES

Effective: April 14, 2003

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.

This notice will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. We have summarized our responsibilities and your rights on this first page. For a complete description of our privacy practices, please review this entire notice.

OUR RESPONSIBILITIES

Our nursing facility is required to:
- Maintain the privacy of your health information
- Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you
- Abide by the terms of this notice

YOUR RIGHTS

As a resident of our nursing facility, you have several rights with regard to your health information, including the following:

- The right to request that we not use or disclose your health information in certain ways
- The right to request to receive communication in an alternative manner or location
- The right to access and obtain a copy of your health information
- The right to request an amendment to your health information
- The right to an accounting of disclosures of your health information

We reserve the right to change our privacy practices and to make the new provisions effective for all health information we maintain. Should our privacy practices change, we will post the changes on the bulletin board in our facility, as well as on our web site. A copy of the revised notice will be available after the effective date of the changes upon request.

We will not use or disclose your health information without your authorization, except as described in this notice.

If you have questions and would like additional information, you may contact our facility’s Contact Officer or the organization’s Privacy Officer.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION

Each time you visit a nursing facility, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

- Basis for planning your care and treatment
- Means of communication among the many health professionals who contribute to your care
- Legal document describing the care you received
- Means by which you or a third party payor can verify that services billed were actually provided
- A tool in educating health professionals
- A source of data for medical research
- A source of information for public health officials who oversee the delivery of health care in the United States
- A source of data for facility planning and marketing
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to: Ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

We use and disclose medical information about you for a number of different purposes. Each of those purposes is described below.

For Treatment

We may use medical information about you to provide, coordinate or manage your health care and related services by both us and other health care providers. For example, information obtained by a nurse, physician, or other member of your healthcare team will be recorded in you record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

We may disclose medical information about you to doctors, nurses, hospitals and other health facilities who become involved in your care. We may consult with other health care providers concerning you and as part of the consultation share your medical information with them. Similarly, we may refer you to another health care provider and as part of the referral share medical information about you with that provider. For example, we may conclude you need to receive services from a physician with a particular specialty. When we refer you to that physician, we also will contact that physician’s office and provide medical information about you to them so they have information they need to provide services for you.

For Payment

We will use or disclose your health information for payment, including for the payment activities of other health care providers or payors. For example, a bill may be sent to you or a third party payor, including Medicare or Medicaid. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

For Health Care Operations

We will use or disclose your health information for our regular health operations. For example, members of the medical staff, the risk or quality assurance manager, or members of the Quality Assurance team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide.

In addition, we will disclose your health information for certain health care operation of other entities. However, we will only disclose your information under the following conditions:

- The other entity must have, or have had in the past, a relationship with you
- The health information used or disclosed must relate to that other entity’s relationship with you
- The disclosure must only be for one of the following purposes:

o Quality assessment and improvement activities
o Population based activities relating to improving health or reducing health care costs
o Case management and care coordination
o Conducting training programs
o Accreditation, licensing, or credentialing activities
o Health care fraud and abuse detection or compliance

Business Associates

There are some services provided in our organization through the use of outside people and entities. Examples of these ?Business Associates? include our accountants, consultants and attorneys. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require the business associates to appropriately safeguard your information.

Notification

Unless you tell us otherwise in writing, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. Depending on the nature of the information that we need to relay, if we are unable to reach your family member or personal representative, then we may or may not leave a message for them on an answering machine, or we may request a call back to the facility.Communication with Family
Unless you tell us otherwise in writing, we may disclose to a family member, other relative, close personal friend or any other person involved in your health care, health information relevant to that person’s involvement in your care or payment related to your care. If there is a family member, other relative, or close personal friend that you do not want us to disclose medical information about you to, please notify the Contact Officer, Admissions Coordinator, or tell our staff member who is providing care to you of your objection.Marketing Communications
We may use and disclose medical information about you to communicate with you about a product or service to encourage you to purchase the product or service. This may be:

- To describe a health-related product or service that is provided by us;
- For your treatment;
- For case management or care coordination for you;
- To direct or recommend alternative treatments, therapies, health care providers, or settings of care.

We may communicate to you about products and services in a face-to-face communication by us to you. We also may communicate about products or services in the form of a promotional gift of nominal value.
All other use and disclosure of medical information about you by us to make a communication about a product or service to encourage the purchase or use of a product or service will be done only with your written authorization.

Fundraising

We may contact you as part of a fund-raising effort.

Resident Directory

Unless you notify us that you object, we may use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and except for religious affiliation, to other people who ask for you by name. We may also use your name on a nameplate next to or on your door in order to identify your room. If you do not want included in our facility directory, or you want to restrict the information we include in the directory, you must notify the Contact Officer or Admissions Coordinator of your objection.

Facility Newsletter

Unless you notify us that you object, we may use your name, birth date, and other information about you (i.e., interview for Resident of the Month feature) for newsletter purposes. If you do not want included in our facility newsletter, or you want to restrict the information we include in the newsletter, you must notify the Contact Officer or Admissions Coordinator of your objection.

Disaster Relief

We may use or disclose medical information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. This will be done to coordinate with those entities in notifying a family member, other relative, close personal friend, or other person identified by you of your location, general condition or death.

Required by Law and Law Enforcement Purposes

We may use or disclose medical information about you when we are required to do so by law. We may disclose medical information about you to a law enforcement official for law enforcement purposes:

- As required by law.
- In response to a court, grand jury or administrative order, warrant or subpoena.
- To identify or locate a suspect, fugitive, material witness or missing person.
- About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
- To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
- About crimes that occur at our facility.
- To report a crime in emergency circumstances.

Public Health Activities

We may disclose medical information about you for public health activities and purposes. This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.

Victims of Abuse, Neglect, Misappropriation or Domestic Violence

We may disclose medical information about you to a government authority authorized by law to receive reports of abuse, neglect, misappropriation or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you; or, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or, if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.

Health Oversight Activities

We may disclose medical information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.

Judicial and Administrative Proceedings

We may disclose medical information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal. We also may disclose medical information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.

Coroners and Medical Examiners

We may disclose medical information about you to funeral directors, coroners or medical examiners for them to carry out their duties consistent with applicable law.

Organ, Eye or Tissue Donation

To facilitate organ, eye or tissue donation and transplantation, we may disclose medical information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue.

Research

We may disclose information to researchers when certain conditions have been met.

To Avert Serious Threat to Health or Safety

We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.

Military

If you are a member of the Armed Forces, we may use and disclose medical information about you for activities deemed necessary by the appropriate military command authorities to assure the proper execution of the military mission. We may also release information about foreign military personnel to the appropriate foreign military authority for the same purposes.

National Security and Intelligence

We may disclose medical information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President

We may disclose medical information about you to authorized federal officials so they can provide protection to the President of the United States, certain other federal officials, or foreign heads of state.

Security Clearances

We may use medical information about you to make medical suitability determinations and may disclose the results to officials in the United States Department of State for purposes of a required security clearance or service abroad.

Inmates; Persons in Custody

We may disclose medical information about you to a correctional institution or law enforcement official having custody of you. The disclosure will be made if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or, (c) the safety, security and good order of the correctional institution.

Workers Compensation

We may disclose your health information the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Mental Health or Chemical Dependency Records

If we receive health information about you from a health care provider, we will not re-dis-close or otherwise reveal any mental health or chemical dependency records contained in that information, beyond the purpose of the disclosure to us, without first obtaining your written authorization or as required by law.

Other Uses and Disclosures

Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying the Contact Officer in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any affect on actions taken by us in reliance on it.

YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of the facility, the information in your health record belongs to you. You have the following rights:

Right to Request Restrictions

You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) for to public or private entities for disaster relief efforts. For example, you could ask that we not disclose medical information about you to your brother or sister. To request a restriction, you may do so at any time on a form provided by the facility.

Although we will consider your requests with regard to the use of your health information, please be aware that we are under no obligation to accept it or to abide by it. We will abide by your requests with regard to the disclosure of you clinical and personal records to anyone outside of the facility, except in an emergency, if you are being transferred to another health care institution, or the disclosure is required by law. 42 C.F.R.§ 483.10(e) provides that a nursing facility must abide by a resident’s right to refuse the release of his/her personal or clinical records to any individual outside of the facility, unless the release is necessary because the resident is being transferred to another health care institution, or that it is required by law. We are not required to agree to any requested restriction. If we do agree to the restriction, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.

Right to Receive Confidential Communications

If you are dissatisfied with the manner in which or the location where you are receiving communications from us that are related to your health information, you may request that we provide you with such information by alternative means or at alternative locations. Such a request must be made in writing to the facility’s Contact Officer. Your request must state how or where you can be contacted. We will attempt to accommodate all reasonable requests. For more information about this right, see 45 C.F.R.§ 164.522(b).

Right to Inspect and Copy

You may request to inspect and/or obtain copies of health information about you, which will be provided to you within the time frames established by law for a reasonable fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.

Facilities Non-Certified for Medicare/Medicaid - To inspect or copy medical information about you, you must submit your request in writing to the Contact Officer and use the facility’s approved ?Authorization for the Release of Health Information?. Your request should state specifically what medical information you want to inspect or copy. For more information about this right, see 45 C.F.R.§ 164.524.

Facilities Certified for Medicare/Medicaid - To inspect or copy medical information about you, you may make a request for access to your records whether orally or in writing. The facility will honor all requests made by a resident whether made orally or in writing. However, in order to better respond to your request, the facility will ask that all requests be put into writing to the Contact Officer and use the facility’s approved "Authorization for the Release of Health Information". Your request should state specifically what medical information you want to inspect or copy.

Right to Amend

You have the right to ask us to amend medical information about you if you believe that any health information in your record is incorrect or if you believe that important information is missing. You have this right for so long as the medical information is maintained by us.

To request an amendment, you must submit your request in writing to the Contact Officer. Your request must state the amendment desired and provide a reason in support of that amendment.

We may deny your request to amend medical information about you if it does not meet the proper requirements.

Right to an Accounting of Disclosures

You have the right to receive an accounting of disclosures of medical information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.

Certain types of disclosures are not included in such an accounting:

- Disclosures to carry out treatment, payment and health care operations;
- Disclosures of your medical information made to you;
- Disclosures that are incident to another use or disclosure;
- Disclosures that you have authorized;
- Disclosures for our facility directory or to persons involved in your care;
- Disclosures for disaster relief purposes;
- Disclosures for national security or intelligence purposes;
- Disclosures to correctional institutions or law enforcement officials having custody of you;
- Disclosures that are part of a limited data set for purposes of research, public health, or health care operations (a limited data set is where things that would directly identify you have been removed.
- Disclosures made prior to April 14, 2003.

Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight agency.

To request an accounting of disclosures, you must submit your request in writing to the Contact Officer. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and may not include dates before April 14, 2003.

Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.

There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.

Right to Copy and Availability of Notice of Privacy Practices

You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even though you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time.

You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site, www.sovereignhealthcare.com

To obtain a paper copy of this notice, contact the facility’s Contact Officer or Admissions Coordinator.

A copy of our current Notice of Privacy Practices will be posted in the designated area. A copy of the current notice also will be posted on our web site, www.sovereignhealthcare.com

Our Right to Change Notice of Privacy Practices

We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the effective date of the new notice.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us in writing on a form provided by the facility. The complaint form may be obtained from the facility’s Contact Officer or the organization’s Privacy Officer. You may also complain to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You will not be retaliated against for filing a complaint.

Questions and Information
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact the facility’s Contact Officer or the organization’s Privacy Officer.