OHIO VALLEY MANOR, = INC

=95 = ; =20 Maintain the = privacy of=20 your health information

=95 = ; =20 Provide you with = this=20 notice of our legal duties and privacy practices with respect to = information we=20 collect and maintain about you

=95 = ; =20 Abide by he = terms of this=20 notice

Your=20 Rights

As a = resident/patient of Ohio=20 Valley Manor, you have several rights with regard to your health = information,=20 including the following:

=95 = ; =20 The right to = request that=20 we not use or disclose your health information in certain=20 ways.

=95 = ; =20 The right to = request to=20 receive communications in an alternative manner or=20 location.

=95 = ; =20 The right to = access and=20 obtain a copy of your health information.

=95 = ; =20 The right to = request an=20 amendment to your health information.

=95 = ; =20 The right to an = accounting=20 of disclosures of your health information.

Ohio Valley Manor = reserves the=20 right to change our privacy practices and to make the new provisions = effective=20 for all health information we maintain. =20 Should our privacy practices change, we will post the changes on = the=20 bulletin board in our facility, as well as on our web site. A copy of the revised notice = will be=20 available after the effective date of the changes upon request.

Ohio Valley Manor = will not use=20 or disclose your health information without your authorization, except = as=20 describe in this notice. =20

If you have = questions and would=20 like additional information, you may contact our facility=92s Privacy = Officer at=20 937-392-4318 Ext. 224

Understanding = Your Health=20 Record/information

Each time you are = admitted to=20 Ohio Valley Manor, a record is made. =20 Typically, this

record contains = your symptoms,=20 examination and test results, diagnoses, treatment, and a plan for = future care=20 or treatment. This = information,=20 often referred to as your health or medical record, serves as=20 a:

=95 = ; =20 basis for = planning your=20 care and treatment

=95 = ; =20 means of = communication=20 among the many health professionals who contribute to your=20 care

=95 = ; =20 legal document = describing=20 the care you received

=95 = ; =20 means by which = you or a=20 third-party payer can verify that services billed were actually=20 provided

=95 = ; =20 a tool in = educating heath=20 professional

=95 = ; =20 a source of data = for=20 medical research

=95 = ; =20 a source of = information=20 for public health officials who oversee the delivery of health care in = the=20 United States

=95 = ; =20 a source of data = for=20 facility planning marketing

=95 = ; =20 a tool with = which we can=20 assess and continually work to improve the care we render and the = outcomes we=20 achieve

Understanding what = is in your=20 record and how your health information is used helps you to: ensure its=20 accuracy, better understand who, what, when, where, and why others may = access=20 your health information, and make more informed decisions when = authorizing=20 disclosure to others.

How We Will = Use or=20 Disclose Your Health Information

(1) = Treatment. Ohio Valley Manor will = use or=20 disclose your health information for treatment purposes, including for = the=20 treatment activities of other health care providers. For example, information = obtained by a=20 nurse, physician, or other member of your healthcare team will be = recorded in=20 your record and used to determine the course of treatment that should = work best=20 for you. Your physician = will=20 document in your record his or her expectations of the members of your=20 healthcare team. Members = of your=20 healthcare team will then record the actions they took and their=20 observations. In that = way, the=20 physician will know how you are responding to treatment. We will also provide your = physician or a=20 subsequent healthcare provider with copies of various reports that = should assist=20 him or her in treating you once you=92ve been discharged form our = nursing=20 facility.

(2) = Payment. Ohio Valley Manor will use or = disclose=20 your health information for payment, including for the payment = activities of=20 other health care providers or payers. =20 For example, a bill may be sent to you or a third-party payer, = including=20 Medicare or Medicaid. The = information on or accompanying the bill may include information that = identifies=20 you, as well as your diagnosis, procedures, and supplies=20 used.

(3) Health care=20 operations. Ohio Valley Manor will use or = disclose=20 your health information for our regular health operations. For example, members of the = medical=20 staff, the risk or quality improvement manager, or members of the = medical staff,=20 the risk or quality improvement team may use others like it. This information will then be = used in an=20 effort to continually improve the quality and effectiveness of the = health care=20 and service we provide.

In addition, Ohio = valley Manor=20 will disclose your health information for certain health care operations = of=20 other entities. However, = we will=20 only disclose your information under the following conditions: (a) the = other=20 entity must have had in the past, a relationship with you; (b) the = health=20 information used or disclosed must relate to that other entity=92s = relationship=20 with you; and (c) the disclosure must only be for one of the following = purposes:=20 ( i ) quality assessment and improvement activities; (ii) = population-based=20 activities relating to improving health or reducing health care costs; = (iii)=20 case management and care coordination; (iv) conducting training = programs; (v)=20 accreditation, licensing, or credentialing activities; or (vi) health = care fraud=20 and abuse detection or compliance.

(4) Business=20 associates. There are = some=20 services provided in organization through the use of outside people and=20 entities. Examples of the = =93business=20 associates=94 include our accountants, consultants and attorneys. Ohio Valley Manor may disclose = your=20 health information to our business associates so that they can perform = the job=20 we=92ve asked to do. To = protect your=20 health information, however, we require the business associates to = appropriately=20 safeguard your information.

(5) = Directory. Unless you notify Ohio Valley = Manor that=20 you object, we may use your name, location in the facility, general = condition,=20 and religious affiliation, to other people who ask for you by name. We may also use your name on a = nameplate=20 next to or on your door in order to identify your room, unless you = notify us=20 that you object.

(6) = Notification. Ohio Valley Manor may use or = disclose=20 information to notify or assist in notifying a family member, personal=20 representative, or another person responsible for your care, of your = location,=20 and general condition. If = we are=20 unable to reach your family member or representative, then we may leave = a=20 message for them at the phone number that they have provided us, e.g., = on an=20 answering machine.

(7) = Communication with=20 family. Ohio Valley = Manor may=20 disclose to a family member, other relative, close personal friend or = any other=20 person involved in your health care, health information relevant to that = person=92s involvement in your care or payment related to your=20 care.

(8) = Research. Ohio Valley Manor may disclose = information to researchers when certain conditions have been=20 met.

(9) Transfer of = information=20 at death. Ohio Valley = may=20 disclose health information to funeral directors, medical examiners, and = coroners to carry out their duties consistent with applicable=20 law.

(10) Organ = procurement=20 organizations. = Consistent with=20 applicable law, we may disclose health information to organ procurement=20 organizations or other entities engaged in the procurement, banking, or=20 transplantation of organs for the purpose of tissue donation and=20 transplant.

(11) = Marketing. Ohio Valley Manor may contact = you=20 regarding your treatment, to coordinate your care, or to direct or = recommend=20 alternative treatments, therapies, health care providers or = settings. In addition, we may contact = you to=20 describe a health-related product or service that may be of interest to = you, and=20 the payment for such product or service.

(12) Fund = raising. We may contact you as part of = a=20 fund-raising effort.

(13) Food and = Drug=20 Administration (FDA). = Ohio=20 Valley Manor may disclose to the FDA, or to a person or entity subject = to the=20 jurisdiction of the FDA, health information relative to adverse events = with=20 respect to food, supplements, product defects, or post marketing = surveillance=20 information to enable product recalls, repairs, or=20 replacement.

(14) Workers=20 compensation. Ohio = Valley Manor=20 may disclose health information to the extent authorized by and to the = extent=20 necessary to comply with laws relating to workers compensation or other = similar=20 programs established by law.

(15) Public = health. As required by law, Ohio = Valley Manor=20 may disclose your health information to public health or legal = authorities=20 charged with preventing or controlling disease, injury, or=20 disability

(16) = Correctional=20 institution. Should = you be an=20 inmate of a correctional institution, Ohio Valley Manor may disclose to = the=20 institution or agents thereof health information necessary for your = health and=20 the health and safety of other individuals.

(17) Law=20 enforcement. Ohio = Valley Manor=20 may disclose health information for law enforcement purposes as required = by law=20 or in response to a valid subpoena.

(18) = Reports. Federal law makes provision = for your=20 health information to be released to an appropriate health oversight = agency,=20 public health authority or attorney, provided that a work force member = or=20 business associate believes in good faith that we have engaged in = unlawful=20 conduct or have otherwise violated professional or clinical standards = and are=20 potentially endangering one or more patients, workers or the=20 public.

Your Health = Information=20 Rights

Although your = health record is=20 the physical property of the nursing facility, the information in your = health=20 record belongs to you. You have the following = rights:

=95 = ; =20 You may request = that Ohio=20 Valley Manor not use or disclose your health information for a = particular reason=20 related to treatment, payment, the Facility=92s general health care = operations,=20 and/or to a particular family member, other relative or close personal=20 friend. For more = information about=20 this right, see 45 Code of Federal Regulations (C.F.R.)=A7 164.522=20 (a).

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=95 = ; =20 Although Ohio = Valley Manor=20 will consider your request with regard to the use of your health = information,=20 please be aware that we are under no obligation to accept it or to abide = by=20 it. We will abide by your = by your=20 request with regard to the disclosure of your clinical and personal = records to=20 anyone to anyone outside of the facility, except in an emergency, if you = are=20 being transferred to another health care institution, or the disclosure = is=20 required by law. 42 = C.F.R. =A7 483.10=20 (e) provides that a NF must abide by a resident=92s right to refuse the = release of=20 his/her personal or clinical records to any individual outside of the = facility,=20 unless the release is necessary because the resident is being = transferred to=20 another health care institution, or the it is required by=20 law.

=95 = ; =20 If you are = dissatisfied=20 with the manner in which or the location where you are receiving = communications=20 from Ohio Valley Manor that are related to your health information, you = may=20 request that we provide you with such information by alternative means = or a at=20 alternative locations. = Such a=20 request must be made in writing, and submitted to Medical Records=20 Department. We will = attempt to=20 accommodate all reasonable requests. =20 For more information about this right, see 45 C.F.R. =A7 164.522=20 (b).

=95 = ; =20 .You may request = to=20 inspect and/or obtain copies of health information about you, which will be provided to you = in the=20 time frames established by law. = You=20 may make such requests orally or in writing; however, in order to better = respond=20 to your request we ask that you make such request in writing on our = facility=92s=20 standard form. I you = request to=20 have copies made, we will charge you a reasonable fee. For more information about = this right,=20 see 45 C.F.R. =A7 164.524.

=95 = ; =20 If you believe = that any=20 health information in your record is incorrect or if you believe that = important=20 information is missing, you may request that Ohio Valley Manor correct = the=20 existing information or add the missing information. Such requests must be made in = writing,=20 and must provide a reason to support the amendment. We ask that you use the form = provided by=20 our facility to make such request. =20 For a request form, please contact the Privacy Officer. For more information about = this right,=20 see 45 C.F.R =A7 164.526.

=95 = ; =20 You may request = that Ohio=20 Valley Manor provide you with a written accounting of all disclosures = made by us=20 during the time period for which you request (not to exceed 6 = years). We ask that such requests be = made in=20 writing on a form provided by our facility. Please note an accounting will = not apply=20 to any of the following types of disclosures: disclosures made for = reasons of=20 treatment, payment or health care operations; disclosures made to you or = your=20 legal representative, or any other individual involved with your care;=20 disclosures to correctional institutions or law enforcement officials; = and=20 disclosures for national security purposes. You will not be charged for = your=20 first accounting request in any 12-month period. However, for any requests that = you make=20 thereafter, you will be charged a reasonable, cost-based fee. For more information about = this right,=20 see 45 C.F.R. =A7 164.528 =20

=95 = ; =20 You have the = right to=20 obtain a paper copy of our Notice Of Privacy Practices upon = request. You may also access and print = a copy of=20 our notice from our website: www.ohiovalleymanor.com.=20

=95 = ; =20 You may revoke = an=20 authorization to use or disclose health information, except to the = extent that=20 action has already been taken. = Such=20 a request must be made in writing.

For More=20 Information or to Report a Problem &nbs= p; =20

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If you = have=20 questions and would like additional information, you may contact our = facility=92s=20 Privacy officer at 937-392-4318 Ext. 224 Medical Records=20 Department. =

If you = believe that=20 your privacy rights have been violated, you may file a complaint with = us. These complaints must be filed = in=20 writing on a form provided by our facility. The complaint form may be = obtained from=20 the Medical Records Department and when completed should be returned to = the=20 office of the Administrator. You may also file a complaint with the = secretary of=20 the Federal Department of Health and Human Services. There will be no retaliation = for filing=20 a complaint.

I hereby acknowledge the receipt of=20 the

Ohio Valley Manor Inc.

Notice of Privacy = Practices.

Date:_____________ &n= bsp; =20 Signed:_______________________