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.

1. General description and purpose of notice.

This notice describes our information privacy practices and that of:

1. Any health care professional authorized to enter information into your medical record created and/or maintained at our facility;
2. Any member of a volunteer group which we allow to help you while receiving services at our facility; and
3. All facility employees, staff, and other personnel.

All of the individuals or entities identified above will follow the terms of this notice. These individuals or entities may share your health information with each other for purposes of treatment, payment, or health care operations, as further described in this notice.

2. 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.

This notice will provide you with information regarding our privacy practices and applies to all of your health information created and/or maintained at our facility, including any information that we receive from other health care providers or facilities. The notice describes the ways in which we may use or disclose your health information and also describes your rights and our obligations regarding any such uses or disclosures. We will abide by the terms of this notice, including any future revisions that we may make to the notice as required or authorized by law.

We reserve the right to change this notice and to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The first page of the notice contains the effective date and any dates of revision.

3. Uses or disclosures of your health information.

We may use or disclose your health information in one of following ways:

1. Pursuant to your written authorization (for purposes other than treatment, payment or health care operations)
2. Pursuant to your verbal agreement (for use in our facility directory or to discuss your health condition with family or friends who are involved in your care);
3. As permitted by law
4. As required by law

The following describes each of the different ways that we may use or disclose your health information. Where appropriate, we have included examples of the different types of uses or disclosures. While not every use or disclosure is listed, we have included all of the ways in which we may make such uses or disclosures.

1. General Uses or disclosures of health information.

Under the Privacy Rules, we are permitted to use and disclose your Health Information for the following purposes, without obtaining your permission or Authorization:

1. 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, medication aides, technicians, medical and nursing students, rehabilitation therapy specialists, or other personnel who are involved in your health care. For example, your physician may order physical therapy services to improve your strength and walking abilities. Our nursing staff will need to talk with the physical therapist so that we can coordinate services and develop a plan of care. We also may disclose your health information to people outside of our facility who may be involved in your health care, such as family members, social services, or home health agencies.
1. Treatment alternatives, Health-related benefits and services. We may use or disclose your health information for purposes of contacting you to inform you of treatment alternatives or healthrelated benefits and services that may be of interest to you.
2. Payment. We may use or disclose your health information so that we may bill and collect payment from you, an insurance company, or another third party for the health care services you receive at our facility. For example, we may need to give information to your health plan regarding the services you received from our facility so that your health plan will pay us or reimburse you for the services. We also may 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.
3. Health care operations. We may use or disclose your 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, medication aides, rehabilitation therapy specialists, technicians, medical and 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.
1. Fundraising activities. We may use a limited amount of your health information for purposes of contacting you to raise money for our facility and its operations. We may disclose this health information to a foundation related to the facility so that the foundation may contact you to raise money for our facility. The information which we may use or disclose will be limited to your name, address, phone number, and dates for which you received treatment or services at our facility. If you do not want our facility or affiliated foundation to contact you for these fundraising purposes, you must notify our Privacy Officer in writing.

2. 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 or health care operations and for purposes which are not permitted or required law. You have the 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
3. A request to provide your health information for purposes of including you on a mailing list
3. 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 religious affiliation, may be given to people who ask for you by name and will also be posted outside each resident's room and/or displayed in various visible locations throughout the facility.
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.
4. Uses or disclosures permitted by law

Certain state and federal laws and regulations either require or permit us to make certain uses or disclosures of 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. The uses or disclosures which we may make pursuant to these laws and regulations include the following:

1. Public health activities. We may use or disclose your health information to public health authorities that are authorized by law to receive and collect health information for the purpose of preventing or controlling disease, injury or disability. We may use or disclose your health information for the following purposes:
1. To report births and deaths
2. To report suspected or actual abuse, neglect, or domestic violence involving a child or an adult
3. To report adverse reactions to medications or problems with healthcare products
4. To notify individuals of product recalls
5. 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 to a health oversight agency that is authorized by law to conduct health oversight activities. These oversight activities may include 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 to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes. We may 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, but only if efforts have been made to (i) notify you of the request for disclosure or (ii) obtain an order protecting your health information.
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 for the following purposes:
1. In response to a court order, subpoena, warrant, summons or similar lawful process
2. To identify or locate a suspect, fugitive, material witness, or missing person
3. Regarding a victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement
4. To report a death that we believe may be the result of criminal conduct
5. To report criminal conduct at our facility
6. In emergency situations, to report a crime-the location of the crime and possible victims; or the identity, description, or location of the individual who committed the crime
6. Coroners, medical examiners, or funeral directors. We may use or disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may use or disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities.
7. 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 for the purpose of facilitating organ or tissue donation or transplantation.
8. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information may be used or disclosed has been approved through this special approval process.

However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying residents with specific health care needs who may qualify to participate in the research project. Any use or disclosure of your health information which may be done for the purpose of identifying qualified participants will be conducted onsite at our facility. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address or other identifying information.

9. 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. Any such use or disclosure would be made solely to the individual(s) or organization(s) that have the ability and/or authority to assist in preventing the threat.
10. Military and veterans. If you are a member of the armed forces, we may use or disclose your health information as required by military command authorities.
11. National security and intelligence activities. We may use or disclose your health information to authorized federal officials for purposes of intelligence, counterintelligence, and other national security activities, as authorized by law.
12. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may use or disclose your health information to the correctional institution or to the law enforcement official as may be necessary (i) for the institution to provide you with health care; (ii) to protect the health or safety of you or another person; or (iii) for the safety and security of the correctional institution.
5. Uses or disclosures required by law

We may use or disclose your information where such uses or disclosures are required by federal, state or local law.

4. 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. Generally, this includes medical and billing records, but does not include psychotherapy notes.

   To inspect and copy your health information, you must submit your request in charge a fee for the costs of copying, mailing, or other supplies associated with your request.

   We may deny your request to inspect and copy your health information in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional selected by our facility will review your request and the denial. The person conducting the review will not be the person who initially denied your request. We will comply with the outcome of this review.

2. Right to request an amendment. If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our facility.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide us with a reason that supports your request.

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

1. was not created by us, unless the person or entity that created the information is no longer available to make the amendment
2. is not part of the health information kept by or for our facility
3. is not part of the information which you would be permitted to inspect and copy
4. is accurate and complete
3. Right to an 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 of health information that we made for purposes of treatment, payment, or health care operations.

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than six (6) years prior to the date of your request and may not include dates before April 14, 2003. Your request should indicate in what form you want to receive the accounting (for example, on paper or via electronic means). The first accounting that you request within a twelve (12)-month period will be free.

For additional accountings, we may charge you for the costs of providing the accounting. 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.

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 family member or friend, who is involved in your care or in the payment of your care. For example, you could ask that we not use or disclose information regarding a particular treatment that you received.

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.

To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply (for example, disclosures to a family member).

5. 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. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

6. Right to a paper copy of this notice. You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, contact our Privacy Officer.

5. Complaints

If you believe your privacy rights have been violated, you may file a complaint with our facility or with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201. Complaints filed directly with the Secretary must be made in writing, must name the entity against whom the complaint is lodged, must describe the acts or omissions in violation of the Privacy Rule or the entity's privacy practices, and must be filed within 180 days of the time you knew or should have known of the violation.

To file a complaint with our facility, contact our Privacy Officer at the following address:

Cogburn Health
& Rehabilitation Huntsville, Inc.
4010 Chris Drive

Huntsville, AL 35802
(256) 883-8656

All complaints must be submitted in writing.

You will NOT be penalized for filing a complaint.

Note: Please be sure to sign the Acknowledgement of Receipt on the following page and return to us.

6. Facility Directory, Resident Care Representatives and Acknowledgement of Receipt

	Please omit my name from the facility directory described in 3a above.
	Please do not disclose my health information to individuals, such as family and friends, who are involved in my care or who help pay for my care, as described in 3b above, without a written authorization from me. Cogburn Health Center, Inc. may disclose my health information to a person or organization assisting in disaster relief efforts for the purpose of notifying my family or friends involved in my care about my condition, status and location.

BY SIGNING BELOW, I HEREBY ACKNOWLEDGE RECEIPT OF THIS PRIVACY NOTICE, AND INDICATE IF I HAVE OPTED NOT TO BE INCLUDED IN THE FACILITY DIRECTORY OR HAVE OPTED NOT TO SHARE HEALTH INFORMATION WITH PERSONS INVOLVED IN MY CARE WITHOUT WRITTEN AUTHORIZATION.

Printed Name of Resident		Date
Signature of Resident or Resident's Representative
Printed Name of Resident's Representative (if applicable)
Representative's Relationship to Resident (if applicable)

To be completed by Belinda Schrimsher, Cogburn Health & Rehabilitation, Huntsville Inc.
After a good faith attempt to obtain an Acknowledgment of Receipt, the resident or representative refused or was unable to sign the Privacy Notice for the following reason(s)

Signature of Cogburn Health Center, Inc. Representative		Date