Privacy Practices & Consent Form          Photo Release & Consent

Effective Date: April 14, 2003
Revision Date: April 14, 2003

Dayspring Village, Inc.
Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE READ IT CAREFULLY

Dayspring Village is covered by the medical information privacy provisions of the
Health Insurance Portability and Accountability Act of 1996 (generally called “HIPAA”)
and its Regulations.  As a result, we are required to comply with HIPPA and the
Regulations in the use and disclosure of health information by which our clients can
be individually identified.  This health information is referred to as “Protected
Health Information” or “PHI” for short.  We are also required under Section 164.520 to
give our clients this notice of our legal duties and privacy practices concerning
their Protected Health Information, and also to tell our clients about their rights under
HIPAA and the Regulations.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

CLIENTS’ PRIOR CONSENT NOT REQUIRED

Treatment. We are permitted to use and disclose our resident’s Protected Health Information in connection with their medical treatment. In doing so, we are to use our professional judgment and experience with common practice in determining what is in the resident’s best interest.

Payment. We are entitled to send Protected Health Information the State Medicaid Plan or to any other business entity involved in our billing system so that we can be paid.

Health Care Operations. We are permitted to provide Protected Health Information for health care operations such as evaluations of the quality of our clients’ health care in order to improve the success of treatment programs.

Other Permitted Uses and Disclosures. There are a number of other specified purposes for which we may disclose a resident’s Protected Health Information without the resident’s prior consent (but with certain restrictions).

Examples include
     Public health activities
     Situations where there may be abuse, neglect or domestic violence
     In connection with health oversight activities
     In the course of judicial or administrative proceedings
     In response to law enforcement inquiries
     In the event of death
     Where organ donations are involved
     In support of research studies
     Where there is a serious threat to health and safety
     In cases of military or veterans’ activities
     Where national security is involved
     For determinations of medical suitability
     For government programs for public benefit
     For workers’ compensation proceedings
     When our records are being audited
     When medical emergencies occur
     And when we communicate with our clients orally or in writing about medications.

RESIDENTS’ PRIOR AUTHORIZATION REQUIRED

For purposes other than those mentioned above, we are required to ask for our residents’ written authorizations before using or disclosing any of their Protected Health Information. If we request an authorization, any of our residents may decline authorization, and if a resident gives us authorization, the resident has the right to revoke the authorization and by doing so, stop any future uses and disclosures of the resident’s health information that the authorization covered.

RESIDENTS’ RIGHTS

HIPPA and the Regulations provide our residents with rights concerning their Protected Health Information. With limited exceptions (which are subject to review), each resident has the right to the following:

Resident’s Record. Each resident can obtain a copy of his or her Protected Health Information by completing our request form. We will charge a reasonable fee for this service.

Accounting for Disclosures. By completing our request form, each resident is entitled to obtain a list of the disclosures of the resident’s Protected Health Information that have occurred within a period of 6 years after April 14, 2003, except for authorized disclosures or disclosures made for the purposes of treatment, payment or healthcare operations, and certain others. There will be no charge for the first request. We will charge a reasonable fee for additional requests.

Amendments. Each resident may ask to change the record or his or her own Protected Health Information by completing our request form and explaining why the change should be made. We will review the request, but may decline to make the change if, in our professional judgment, we conclude that the record should not be changed.

Communications. By completing our request form, each resident can ask us to communicate with him or her about their own Protected Health Information in a confidential manner such as by sending mail to an address other than the home address or using a particular telephone number.

Special Restrictions. By completing our request form, each resident can ask us to adopt special restrictions that further limit our use and disclosure of the client’s Protected Health Information (except where use and disclosure are required of us by law or in emergency circumstances). We will consider the request; but in accordance with HIPAA and the Regulations, we are not required to agree with the request.

Complaints. If a resident believes that we have violated the resident’s rights as to the resident’s Protected Health Information under HIPAA and the Regulations, or if a resident disagrees with a decision we made about access to the resident’s Protected Health Information, the resident has the right to complete our complaint form and deliver it to our contact person listed below. Our contact person is required to investigate, and if possible, to resolve each such complaint, and to advise the resident accordingly. The resident also has the right to send a written complaint to:
        Office for Civil Rights
        U.S. Department of Health and Human Services
        200 Independence Avenue, SW
        Room 509F, HHH Building
        Washington DC 20201

Under no circumstances will Dayspring Village, Inc. retaliate against any resident for filing a complaint.

We are required by law to protect the privacy of our residents’ Protected Health Information, to provide this notice about our privacy practices, and follow the privacy practices that are described in this notice. We reserve the right to make changes in our privacy practices that will apply to all the Protected Health Information we maintain. A new notice will be available on request before any significant change is made.

Contact:         Douglas D. Adkins
Email:             dadkins777@bellsouth.net
Telephone:    904-845-7501
Fax:                904-845-2910