Purpose of this Notice

This notice tells you about how each of the health care facilities and services that are affiliated with Mather (collectively, “Mather”, “We” or “Us”) use and disclose your medical information. It tells you about your rights and our responsibilities to protect the privacy of your medical information. It also tells you how to file a complaint with us or the government if you believe that we have violated any of your rights or any of our responsibilities.

We are required by law to maintain the privacy of your medical information. We must give you a copy of this notice and get your signature that you have received it. We must follow the terms of this notice that are currently in effect.

If we revise this notice, a copy of the revised notice will be available upon request, posted at our location and on our website. We may change our practices and those changes may apply to medical information we already have about you as well as any new information.

This notice will be given to you on the date that you first receive medical services from Mather. In an emergency, we will give you the notice as soon as possible after the emergency treatment has been given.

How We Use or Disclose Your Medical Information

For Treatment

We will use medical information about you to provide you with treatment and services. We may share this information with members of our health care staff or with others involved in your care such as doctors, nurses, or other health care facilities. For example, a nurse who is caring for you will report any changes in your condition to your doctor. We also may disclose your health information to a member of your family or other person who is involved in your care.

For Payment

We may use or disclose your medical information to bill and collect payment for the services we provide to you. For example, we may provide information about your diagnosis, treatment and supplies used to your health insurance plan to the extent necessary to get paid for the services we provide. We may also contact your insurance plan to confirm your coverage or to request prior approval for a planned treatment or service.

Health Care Operations

We may use or disclose your medical information to improve the operations of Mather. For example, we may use your medical information to evaluate our services, including the performance of our staff in caring for you. We may also use this information to learn how to continually improve the quality, effectiveness and efficiency of the health care services that we provide to you.

Common Disclosures for Treatment, Payment or Health Care Operations

Following are some common ways in which information about you may be used for treatment, payment or operations purposes:

We may contact you by telephone or by mail at your home or your office to remind you of an appointment you have with us or anything else about the health care services we provide or payment for your health care services. We may leave messages for you. If you want us to contact you in a certain way or at a certain location, see “Right to Receive Confidential Communications” in this notice.

Your name and address may be used to send you resident or patient satisfaction surveys.

There are some services that are provided for us by our business associates such as accountants, consultants and attorneys. Whenever we share information with our business associates we require them to protect the privacy of your medical information. In addition, they are required by law to comply with HIPAA privacy and security regulations.

Other Use and Disclosures of Your Medical Information

Fund-raising

We may contact you to invite you to a fund-raising event or to send you a newsletter. If you do not want to receive these communications, you have the right to opt out by notifying Our Designee as further described in the Contact Information section below.

Treatment Alternatives

We may use and disclose information about you to tell you about other health care treatment available to you. If you do not want to receive these communications, please notify Our Designee in writing.

Health Related Benefits and Services

We may use and disclose information about you to tell you about other health care benefits or services that may interest you. If you do not want to receive these communications, please notify Our Designee in writing.

Individuals Involved in Your Care

We may disclose information about you to a family member, other relative, close friend or any other person identified by you if they are involved in your care or payments related to your care. We may also use or disclose information about you to notify those persons of your location, general condition or death. If there is a family member, other relative or close friend to whom you do not want us to disclose information about you, please notify Our Designee in writing.

Patient Directory

When you are a resident in a Mather health care community, we may disclose your name, room number, and your medical condition described in general terms to callers or visitors who ask for you by name. We also may provide your religious affiliation to members of the clergy who ask for this information. If you do not want to be included in our directory or you wish to limit the information we include in the directory you must notify Our Designee of your objection.

Use or Disclosures That Are Required or Permitted by Law

Disaster Relief

We may use or disclose information about you to assist in disaster relief efforts. We may need to notify family members or others of your location, general condition or death in case of a natural or man-made disaster.

Required by Law

We may use or disclose information about you when the law requires us to do so.

Communicable Diseases

We may disclose information about you to a person who may have been exposed to an infectious disease or who is at risk of spreading the disease or condition.

Public Health Activities

We may disclose information about you for public health activities to prevent or control disease.

Victims of Abuse, Neglect or Domestic Violence

We may disclose information about you to a government agency if we believe you are the victim of abuse, neglect or domestic violence.

Health Oversight Activities

We may disclose information about you to a health oversight agency.

Food and Drug Administration

We may disclose information about you to the Food and Drug Administration (FDA) to allow them to monitor drugs or devices controlled by the FDA.

NOTICE OF PRIVACY PRACTICES

We may disclose information about you in response to a court proceeding, in response to a subpoena or other legal process.

NOTICE OF PRIVACY PRACTICES

We may disclose information about you to law enforcement officials for law enforcement purposes:

• As required by law.
• In response to a court order or other legal proceeding.
• To identify or locate a suspect, fugitive, material witness or missing person.
• When information is requested about an actual or suspected victim of a crime.
• To report a death as a result of possible criminal conduct.
• About crimes that occur on our premises.
• To report a crime in emergency circumstances.

Funeral Directors, Coroners and Medical Examiners

We may disclose information about you as needed to allow these people to do their jobs.

Organ and Tissue Procurement

We may disclose information about you to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Workers’ Compensation

We may disclose information about you to comply with workers’ compensation laws that provide benefits for work-related injuries or illnesses.

Public Health or Safety

We may use or disclose information about you if we believe it is necessary to prevent a threat to the health or safety of a person or the general public.

Military

If you are a member of the Armed Forces, we may use and disclose medical information about you to your military command.

National Security and Intelligence

We may disclose information about you to authorized federal officials for national security and intelligence activities.

Specialized Government Functions

We may use or disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.

Inmates

We may disclose information about you to a correctional institution or law enforcement official who has custody of you.

Research

We may disclose your information to researchers under certain limited circumstances.

Uses or Disclosures That Require Your Authorization

Other uses and disclosures will be made only with your written authorization. You may cancel your authorization at any time by notifying Our Designee in writing of your desire to cancel it. If you cancel an authorization, it will not have any affect on information that we have already used or disclosed. Some examples of uses or disclosures that require your written authorization are:

Psychotherapy Notes

We must obtain your written permission to disclose psychotherapy notes except in certain circumstances. For example, written permission is not required for use of those notes by the author of the notes with respect to your treatment, or use or disclosure by us for training of mental health practitioners, or to defend Mather in a legal action brought by you.

Marketing

We must obtain your written permission to use your information for marketing purposes except in certain circumstances. We are prohibited from selling lists of patients’ information to third parties or from disclosing your information to a third party so that they can send you information on their products or services without getting your written permission first.

Sale of PHI

We must obtain your written permission to disclose your medical information in exchange for remuneration.

Other Uses and Disclosures

Other Uses and Disclosures of your information not covered by the categories included in this Notice or applicable laws, rules or regulations will be made only with your written permission or authorization.

Restriction From Using/Disclosing Genetic Information for Underwriting Purposes

We may not share any genetic information about you with insurers for purposes of underwriting of insurance policies or send to your employer or potential employer.

Your Rights

The information contained in your health or medical record is the physical property of Mather. The information in it belongs to you. You have the following rights:

Right to Request Restrictions

You have the right to ask us not to use or disclose your information for a particular reason related to treatment, payment or our operations. You may ask that family members or other individuals not be informed of specific information. Those requests must be made in writing to Our Designee. We do not have to agree to your request, unless the request is to restrict disclosures to a health plan for payment or health care operations purposes, if the request is not otherwise required by law, or if the information pertains solely to a health care item or service for which payment has been made in full by you or other third party on your behalf. If we agree to any request for a restriction, we must keep our agreement, except in the case of a medical emergency. Either you or Mather can stop a restriction at any time.

Right to Receive Confidential Communications

You have the right to ask that we communicate with you in a certain way or at a certain place. If you want to request confidential communications the request must be made in writing to Our Designee.

Right to Inspect and Copy Your Medical Information

You have the right to ask to inspect and obtain a copy of your medical information. You must submit your request in writing to Our Designee. If you request a copy of the information or we provide you with a summary of the information we may charge a fee for the costs of copying, summarizing and/or mailing it to you.

If we agree to your request we will tell you. We may deny your request under certain limited circumstances. If your request is denied, we will let you know in writing and you may be able to request a review of our denial.

In addition, if we maintain your medical record in electronic format, you have the right to request a copy of your medical record in electronic format.

Right to Request Amendments to Your Medical Information

You have the right to request that we correct your information. If you believe that any information in your record is incorrect or that important information is missing, you must submit your request for an amendment in writing to Our Designee.

We do not have to agree to your request. If we deny your request we will tell you why. You have the right to submit a statement disagreeing with our decision. We may deny your request if we determine that the information:

• Was not created by us.
• Is not part of the medical information that we maintain.
• Is in records that you are not allowed to inspect and copy.
• Is already accurate or complete.

Right To An Accounting of Disclosures of Health Information

You have the right to find out what disclosures of your information have been made. The list of disclosures is called an accounting. The accounting may be for up to six (6) years prior to the date on which you request the accounting.

Requests for an accounting of disclosures must be submitted in writing to Our Designee. You are entitled to one free accounting in any twelve (12) month period. We may charge you for the cost of providing additional accountings. If there will be a charge, we will notify you in advance.

Right To Obtain a Copy of the Notice

You have the right to ask for and get a paper copy of this notice and any revisions we make to the notice at any time.

Right To Notification of a Breach

You have the right to be notified in the event of a data breach of your medical information.

Right To Restrict Sharing of Information With Your Health Plan

If you pay in cash, you have the right to request that we do not share your information with your health plan.

Complaints and Contact Information

You have the right to complain to us and to the United States Secretary of Health and Human Services if you believe we have violated your privacy rights. There is no risk involved if you file a complaint.

To file a complaint with us, contact Our Designee by phone, email or by mail:

Samia Amamoo, VP, Risk Management, Privacy & Corporate Compliance Officer
Mather
1603 Orrington Avenue, Suite 1800
Evanston, Illinois 60201

Phone: (847) 492.7500

To file a complaint with the United States Secretary of Health and Human Services send your complaint to him or her in care of:

Region V, Office for Civil Rights
U.S. Department for Health and Human Services
233 North Michigan Avenue, Suite 240
Chicago, Illinois 60601

FAX: (312) 886.1807

E-MAIL: OCRComplaint@hhs.gov

Questions and Information

If you have any questions or want more information about this Notice of Privacy Practices, please contact Our Designee at the address set forth above.

The current effective date of this Privacy Notice is: September 19, 2013