Diakon Lutheran Social Ministries and its affiliated entities (listed on Exhibit A) are required by law to maintain the privacy of your medical information, provide you with information about your individual rights and to abide by the terms of this notice. Diakon and its programs and facilities will be collectively referred to in this notice as “we,” “us” or “Diakon.” Diakon reserves the right to change this notice at any time. Any change in the terms of this notice will be effective for all medical information that we are maintaining at that time. We will always post a copy of our current notice at our service locations and facilities and on our Web site at www.diakon.org and will make additional copies available to you upon request. If any change is made to this notice, we will provide you with a written revised notice upon request.

If you have any questions or comments about this notice or if you wish to obtain further information, please contact our Privacy/Contact Officer:

The Rev. Lisa M. Leber, Esq.
Senior Vice President/Chief Legal & Compliance Officer
Diakon Lutheran Social Ministries

960 Century Drive

Mechanicsburg, PA 17055

(717) 795-0434

All communications to our Privacy/Contact Officer must specify your name and contact information, as well as the facility or program in which you are a patient, resident, client or otherwise receiving our services, in order for us efficiently to address your request.


I. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

We may use or disclose your medical information as necessary for your treatment, payment and our health care operations. We have provided examples of the types of uses and disclosures listed below. Not every use or disclosure in these categories will be listed; however, all of the ways in which we are permitted to use and disclose your medical information will fall within one of the categories listed in this notice.

A. For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, therapists, counselors or any of our personnel who are involved in taking care of you at the facility in which you reside or the program from which you receive services. We may also disclose medical information about you to people outside of our facilities or programs who may be involved in your medical care while you are receiving services from us or when you are transferred to a hospital or other facility or when you are discharged from any of our facilities or programs. For example, we may disclose your medical information to a pharmacy to fill a prescription or to a hospital, hospice or home health agency or other type of health care provider to which you are transferred for treatment.

B. For Payment. We may use and disclose medical information about you so that the treatment and services you receive from us and other providers may be billed and payment may be collected from you, an insurance company or another third party such as Medicare and Medicaid (Medical Assistance). For example, we may disclose your medical information to your health insurance company or to Medicare and Medicaid (Medical Assistance) to determine whether a particular service is covered or if you are eligible for Medicaid (Medical Assistance). We may also need to disclose your medical information to your health insurance company or for Medicare or Medicaid reimbursement to demonstrate the medical necessity of the services provided to you or for your stay at one of our facilities or for any other service provided to you. We may also disclose your medical information to another health care provider involved in your care for that provider's billing. For example, we may disclose your medical information to a doctor who provided your care so that the doctor may obtain payment for those services.

C. For Health Care Operations. We may use or disclose your medical information for our own health care operations in order for us to provide quality care to our residents, clients, patients or other persons receiving our services. 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 residents, clients or other persons receiving our services to decide what additional services we should offer. We may disclose information to doctors, nurses and other facility personnel for review and learning purposes.


II. OTHER USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION

In the event that state or other federal law affords more protection with respect to disclosing your medical information, we are required to follow such state or other federal law.

A. Business Associates. We may disclose medical information to "business associates" who provide contracted services such as accounting, legal representation, claims processing, accreditation, and consulting. If we do disclose medical information to a business associate, we will do so subject to a contract that provides that such information will be kept confidential by the business associate.

B. Individuals Involved in Your Care or Payment for Your Care. Unless you object, 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 to pay for your care. We may also inform your family or friends about your general condition, location or death.

C. Appointment/Visit Reminders. We may use and disclose medical information to contact you for a reminder about your scheduled home health or hospice visits, counseling services or for any other scheduled appointment with any of our facilities or with any of our personnel.

D. Fundraising Activities. We may contact you to request financial support for our facilities and our services and programs. We will use only information such as your name, address, telephone number and the dates of treatment in our program or dates of your stay at our facility. If you do not wish to be contacted for fund-raising efforts, please notify the Privacy/Contact Officer, in writing, at the address identified above. We will not share your information with anyone else for another entity's fund-raising purposes.

E. 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.

F. Workers' Compensation. We may release medical information about you for Workers' Compensation or similar programs.

G. Public Health Activities. We may disclose information about you for public health activities. These activities generally include, but are not limited to: prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; or report reactions to medications or problems with products.

H. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.

I. Research. We may allow your medical information to be disclosed for research purposes, provided, however, that the person or entity performing the research adheres to certain privacy practices.

J. 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 actions or other legal proceedings. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

K. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

L. Victims of Abuse, Neglect or Domestic Violence. We may disclose your medical information to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. We will only make this disclosure if we are required or authorized to do so by law or if you agree to such disclosure.

M. Judicial and Administrative Proceedings. 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 involved in the dispute, but only if efforts have been made to notify you about the request or to obtain an order protecting the information requested.

N. Law Enforcement. We may release medical information if asked to do so by a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, reporting criminal conduct in our facility or program, complying with a court order or subpoena and other law enforcement purposes.

O. Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of your death. We may also release medical information about our residents, clients, hospice or home health patients or any other recipients of our services to funeral directors as necessary for them to carry out their duties.

P. 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.

Q. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when we determine it is 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.

R. Military and Veterans. If you are a member of the Armed Forces, we may use and disclose your medical information as required by military command authority. We may also use and disclose your medical information about foreign military personnel as required by the appropriate foreign military authority.

S. Treatment Alternatives/Health Related Benefits and Services. We may use or disclose your medical information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

T. Disaster Relief. We may disclose your health information to an organization assisting in a disaster relief effort.

U. Facility Directory. If you are a resident of one of our residential communities, unless you object, we will include certain limited information about you in our internal facility directory. This information may include your name, your location in the facility, your general condition and your religious affiliation. Our directories do not include specific medical information about you. We may release information in our directories, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.


III. OTHER USES OF MEDICAL INFORMATION REQUIRING AUTHORIZATION

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 with permission to use or disclose your medical information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your medical information 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 we are required to keep records of the care that we provided to you.


IV. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

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

A. Right to request restrictions. You have the right to request that we restrict the uses or disclosures of your medical information 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) 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. We are not required to agree to any requested restriction, but will tell you in advance if we cannot comply. However, if we do agree, we will follow that restriction unless the information is needed to provide you with emergency treatment.

You must submit your limitation or restriction request in writing to your caseworker, counselor, or facility administrator. In your request, you must tell us (1) what information you would like to limit or restrict, (2) whether you wish to limit the use or disclosure, or both, and (3) to whom you would like the limits to apply, for example, disclosures to your spouse. Your request must also specify your name and contact information as well as the facility or program in which you are a patient, resident, client or otherwise receiving our services in order for us to efficiently address your request.

We may terminate your restriction if: (a) you agree or request the termination in writing; (b) you orally agree to the termination; or (c) if we inform you that we are terminating our agreement to your restriction, except that such termination will only be effective for your medical information that is created or received after you receive our notice of termination.

B. Right to receive confidential communications. We will accommodate reasonable requests to receive communications about your medical information from us by alternative means or to alternative locations. For example, you may ask that we contact you only by mail or at work. We will not require you to tell us why you are asking for the confidential communications. If you want to request confidential communications, you must make your request in writing to your caseworker, counselor or facility administrator. Your request must also specify your name and contact information as well as the facility or program in which you are a patient, resident, client or otherwise receiving our services in order for us to efficiently address your request.

C. Right to inspect and copy protected health information. With a few very limited exceptions, you have the right to inspect and obtain a copy of your medical information. To inspect or copy your medical information, you must submit your request in writing to your caseworker, counselor or facility administrator. Your request should specifically state what medical information you want to inspect or copy. Your request must also specify your name and contact information as well as the facility or program in which you are a patient, resident, client or otherwise receiving services in order for us to efficiently address your request. We will ordinarily act on your request within 30 days of our receipt of your request. In the event that state or other federal law requires us to act on your request within a shorter time frame, we will comply with such law. We may charge a fee for the costs of copying, mailing or other supplies associated with your request and will tell you the fee amount in advance.

We may deny your request to inspect and copy in limited circumstances. If you are denied access to your medical information, you may submit a written request that such denial be reviewed to the Privacy/Contact Officer at the address indicated above. In certain circumstances you will not be granted a review of a denial. Otherwise, your denial of access will be reviewed by a licensed health care professional designated by us who did not participate in the original decision to deny access. We will ordinarily act on your request for review within 30 days.

D. Right to amend protected health information. You have the right to request an amendment to your medical information for as long as the information is kept by or for us. Your request must be submitted in writing to the Privacy/Contact Officer and must specifically state your reason or reasons for the amendment. Your request must also specify your name and contact information as well as the facility or program in which you are a patient, resident, client or otherwise receiving our services in order for us to efficiently address your request. We will ordinarily act on your amendment request within 60 days after our receipt of your request.

We may deny your request to amend medical information if we determine that the information: (1) was not created by us; (2) is not part of the medical information maintained by us; (3) would not be available for you to inspect or copy; or (4) is accurate and complete.

If we grant the request, we will inform you of such acceptance in writing. We will make the appropriate amendment to your medical information and we will request that you identify and agree that we may notify all relevant persons with whom the amendment should be shared: (a) individuals that you have identified as having medical information about you and (b) business associates that we know have your medical information that is the subject of the amendment.

E. Right to receive an accounting. You have the right to request an "accounting of disclosures" for disclosures of your medical information that are made after April 14, 2003. The list of disclosures does not include disclosures: (a) for treatment, payment and healthcare operations; (b) made with your authorization or consent; (c) to your family member, close relative, friend or any other person identified by you; or (d) for national security or intelligence purposes. Additionally, under certain circumstances, government officials can request that we withhold disclosures from the accounting.

To request an accounting of disclosures, you must submit your request in writing to your counselor, caseworker or facility administrator. Your request must state the time period for which you would like an accounting which may not be longer than 6 years and cannot include dates before April 14, 2003. Your request must also specify your name and contact information as well as the facility or program in which you are a patient, resident, client or otherwise receiving our services in order for us to efficiently address your request. Your first accounting request within any 12-month period will be provided to you free of charge. For additional accounting lists, we may charge you for the costs of providing the list. We 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.

We will ordinarily act on your accounting request within 60 days of your request. We are permitted to extend our response time for a period of up to 30 days if we notify you of the extension. We may temporarily suspend your right to receive an accounting of disclosures of your medical information, if required to do so by law.

F. Right to a paper copy of this notice. You have the right to a paper copy of this notice. You may request a copy of this notice at any time from any Diakon facility or program or on our Web site at www.diakon.org. Even if you have previously agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.


V. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Diakon Lutheran Social Ministries or with the Department of Health and Human Services, Office of Civil Rights. Complaints to Diakon Lutheran Social Ministries must be submitted in writing to the Privacy/Contact Officer at the address above.

To file a complaint with the United States Secretary of Health and Human Services, send your written complaint to: Region III, Office for Civil Rights, U.S. Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia PA 19106-9111.

You will not be penalized for filing a complaint.

• Diakon Lutheran Social Ministries
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• Diakon Youth Services

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