Trinity Senior Living Communities
NOTICE OF PRIVACY PRACTICES
Version Number 04142003.1

Effective Date: April 14, 2003

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.

We are required by law to maintain the privacy of individually identifiable resident health information (this information is "protected health information" and is referred in this document as "PHI"). We are also required to provide residents with a Notice of Privacy Practices regarding PHI. We are required to post this Notice in a prominent place within our facility. We will only use or disclose your PHI as permitted or required by applicable state law. This Notice applies to your PHI in our possession including the medical records generated by us.

We understand that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how we will use and disclose your PHI.

This Notice applies to the delivery of health care by this facility, its parent, Trinity Senior Living Communities (TSLC), and the facility's medical directors and clinical staff. This Notice also applies to the utilization review and quality assessment activities of TSLC as a member of Trinity Health, a Catholic health care system with facilities in 7 states.

I. Permitted Use or Disclosure

A. Treatment: We will use and disclose your PHI in the provision and coordination of heath care to carry out treatment functions.

• We will disclose all or any portion of your resident medical record information to our medical directors, your attending physician, consulting physician(s), nurses, technicians, medical students and other health care providers who have a legitimate need for such information in your care and continued treatment.
• This facility is a Catholic sponsored health care provider. Spiritual care providers are members of our care staff and will be a part of the team of care providers who use your medical information to provide health care services to you when you are in this facility.
• We will share medical information about you in order to coordinate specific services, such as lab work, x-rays and prescriptions.
• We also will disclose your medical information to people or entities outside TSLC who will be involved in your medical care during and after you leave this facility, such as family members, clergy and others who will provide services that are part of your care.
• We will share certain information such as your name, address, employment, insurance carrier, emergency contact information and appointment scheduling information in an effort to coordinate your treatment with us and with other health care providers.
• We will use and disclose your PHI to inform you of, or recommend possible treatment options or alternatives that will be of interest to you.

B. Payment: We will disclose PHI about you for the purposes of determining coverage, eligibility, funding, billing, claims management, medical data processing, stop loss / reinsurance and reimbursement.

• Medical information will be disclosed to an insurance company, third party payer, third party administrator, health plan or other health care provider (or their duly authorized representatives) involved in the payment of your medical bill and will include copies or excerpts of your medical records which are necessary for payment of your account. It will also include sharing the necessary information to obtain pre-approval for payment for treatment from your health plan.
• We will disclose PHI to collection agencies and other subcontractors engaged in obtaining payment for care.

C. Health Care Operations: We will use and disclose your PHI during routine health care operations including quality assurance, utilization review, medical review, internal auditing, accreditation, certification, licensing or credentialing activities, and for educational purposes.

• For instance, we will need to share your demographic information, diagnosis, treatment plan and health status for population based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, and contacting health care providers and residents with information about treatment alternatives, in order for us to operate our business in an efficient, safe and legal manner.

D. Other Uses and Disclosures: As part of treatment, payment and health care operations, we may also use your PHI for the following purposes:

• Birthday celebrations and other activities related to the residential nature of our facility.
• Taking and displaying photos of residents throughout the building to help our facility feel more like a home.
• We may also use and disclose some of your PHI for fundraising activities.
• Medical Research: We may disclose your PHI without your authorization to medical researchers who request it for approved medical research projects; however, with very limited exceptions such disclosures must be cleared through a special approval process before any PHI is disclosed to the researchers. Researchers will be required to safeguard the PHI they receive.
• We will use and disclose some of your PHI for certain health promotion activities. For example, your name and address may be used to send you newsletters or general communications.

E. See State specific detail at the end of the Notice of Privacy Practices.

II. Permitted Use or Disclosure with an Opportunity for You to Agree or Object

A. Family/Friends: We will disclose PHI about you to a friend or family member who is involved in your medical care. We will also give information to someone who helps you pay for your care. In addition, we will disclose PHI about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status and location. You have a right to request that your PHI not be shared with some or all of your family or friends.

B. Resident Roster: We will include certain limited information about you in the Resident Roster for this facility while you are a resident. This information will include your name, room number, your general condition (e.g., fair, stable, critical, etc.) and your religious affiliation (if you want this included). This is so your family and friends can visit you and know how you are doing. The Resident Roster, except for your religious affiliation, will also be disclosed to people who ask for you by name. The Resident Roster also will be used by other residents. You have the right to request that your name not be included in the Resident Roster. If you request to opt out of the Resident Roster, we cannot inform visitors of your presence, location, or general condition. We generally disclose the resident's death and contact information about funeral arrangements in response to a Resident Roster inquiry after the resident's next of kin have been notified.

C. Spiritual Care: Resident Roster information including your religious affiliation will be given to a member of the clergy, such as a priest or rabbi, if they request information about our residents. We may notify your local religious organization, by disclosing your name that you are at this facility and your condition. A spiritual care provider may be called in to consult regarding your care. Spiritual care providers are members of the health care team at this facility. You have a right to request that your name not be given to any member of the clergy.

D. Promotional Communications: We do not share or sell your PHI to companies that market health care products or services directly to consumers for use by those companies to contact you, such as drug companies. TSLC does maintain a database of residents for promotional communications, disease management, health promotion, and fundraising purposes. This database includes residents to whom we may have sent news about this facility previously and also residents who have donated to or who have expressed an interest in donating to our facility. You may be included in this database. If you wish to be deleted from this database, you may notify the Administrator at this facility.

III. Use or Disclosure Requiring Your Authorization

A. Marketing: We are not permitted to disclose your PHI for marketing to you of any other company's products or services unless you have signed an authorization.

B. Research: We may use or disclose your PHI as part of research that includes providing you with treatment. For example, if you are part of a research study that includes treatment, we may require that you sign an authorization to allow the researchers to use or disclose your PHI for this research.

C. Other Uses: Any uses or disclosures that are not for treatment, payment or operations and that are not permitted or required for public policy purposes or by law will be made only with your written authorization. Written authorizations will let you know why we are using your PHI. You have the right to revoke an authorization at any time.

IV. Use or Disclosure Permitted by Public Policy or Law without your Authorization

A. Law Enforcement Purposes: We will disclose your PHI for law enforcement purposes as required by law, such as responding to a court order or subpoena, identifying a criminal suspect or a missing person, or providing information about a crime victim or criminal conduct.

Required by Law: We will disclose PHI about you when required by federal, state or local law to make reports or other disclosures. We also will make disclosures for judicial and administrative proceedings such as lawsuits or other disputes in response to a court order or subpoena. We will disclose your medical information to government agencies concerning victims of abuse, neglect or domestic violence. We will report drug diversion and information related to fraudulent prescription activity to law enforcement and regulatory agencies. Specialized government functions will warrant the use and disclosure of PHI. These government functions will include military and veteran's activities, national security and intelligence activities, and protective services for the President and others. We will make certain disclosures that are required in order to comply with workers' compensation or similar programs.

B. Coroners, Medical Examiners, Funeral Directors: We will disclose your PHI to a coroner or medical examiner. For example, this may be necessary to identify a deceased person or to determine a cause of death. We will also disclose your medical information to funeral directors as necessary to carry out their duties.

C. Organ Procurement: We may disclose PHI to an organ procurement organization or entity for organ, eye or tissue donation purposes.

D. Health or Safety: We will use and disclose PHI to avert a serious threat to health and safety of a person or the public. We will use and disclose PHI to Public Health Agencies for immunizations, communicable diseases, etc. We will use and disclose PHI for activities related to the quality, safety or effectiveness of FDA-regulated products or activities, including collecting and reporting adverse events, tracking and facilitating product recalls, etc. and post marketing surveillance. Any resident receiving a medical device subject to FDA tracking requirements may refuse to disclose, or refuse permission to disclose, their name, address, telephone number and social security number, or other identifying information for the purpose of tracking.

V. Your Health Information Rights

Although we must maintain all records concerning your treatment at this facility, you have the following rights concerning your PHI:

A. Right to Inspect and Copy: In addition to your rights as a resident of a nursing facility, you have the right under HIPAA to access your PHI and to inspect and copy your PHI as long as we maintain it except for: psychotherapy notes, information that will be used in a civil, criminal or administrative action or proceeding, and where prohibited or protected by law. We will deny your request for access to your PHI without giving you an opportunity to review that decision if:

• You don't have the right to inspect the information; or it is otherwise prohibited or protected by law;
• Disclosing the information would threaten the safety of any person who is responsible for transporting you;
• You are involved in a clinical research project and we created or obtained the PHI during that research. Your access to the information will be temporarily suspended for as long as the research is in progress;
• We obtained the information that you seek access to from someone other than the health care provider under a promise of confidentiality and your access request is likely to reveal the source of the information; or
• Under other limited circumstances. In these instances, however, we will allow the review of its decision by a health care professional that we have chosen. This person will not have been involved in the original decision to deny your request.

Under HIPAA, we request that you make your requests to copy your PHI in writing to us. We are required by HIPAA to respond to your request within 30 days of its receipt. However, under other laws, you are entitled to see your records within 24 hours (excluding hours occurring during a weekend or holiday) after making such a request. If we cannot provide the copies within 30 days, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 60 days of its receipt.

B. Right to Amend: You have the right to amend your PHI for as long as this facility maintains it. However, we will deny your request for amendment if:

• We did not create the information;
• The information is not part of the designated record set;
• The information would not be available for your inspection (due to its condition or nature); or
• The information is accurate and complete.

If we deny your request for changes in your PHI, we will notify you in writing with the reason for the denial. We will also inform you of your right to submit a written statement disagreeing with the denial. You may ask that we include your request for amendment and the denial any time that we disclose the information that you wanted changed. We may prepare a rebuttal to your statement of disagreement and will provide you with a copy of that rebuttal.

You must make your request for amendment of your PHI in writing to this facility, including your reason to support the requested amendment. We will respond to your request within 60 days of its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 90 days of its receipt.

C. Right to an Accounting: You have a right to receive an accounting of the disclosures of your PHI that we have made, except for disclosures:

• To carry out treatment, payment or health care operations;
• To you;
• To persons involved in your care;
• For national security or intelligence purposes;
• To correctional institutions or law enforcement officials; or
• That occurred prior to April 14, 2003.

For each disclosure, you will receive: the date of the disclosure, the name of the receiving organization and address if known, a brief description of the PHI disclosed and a brief statement of the purpose of the disclosure or a copy of the written request for the information, if there was one.

You must make your request for an accounting of disclosures of your PHI in writing to this facility. You must include the time period of the accounting, which may not be longer than 6 years. We will respond to your request within 60 days from its receipt. If we cannot, we will notify you in writing to explain the delay and the date by which we will act on your request. In any event, we will act on your request within 90 days of its receipt. In any given 12-month period, we will provide you with an accounting of the disclosures of your PHI at no charge. Any additional requests for an accounting within that time period will be subject to a reasonable fee for preparing the accounting.

D. Right to Request Restrictions: Under HIPAA you have the right to request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or health care operations functions or to prohibit such disclosure. We will consider your request but may not be able to fully act on your request.

E. Right to Confidential Communications: You have the right to receive confidential communications of your PHI by alternative means or at alternative locations. For example, you may request that we only contact you at work or by mail.

F. Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice of Privacy Practices, upon request.

VI. Complaints

If you believe your privacy rights have been violated, you may file a complaint with this facility, it parent, TSLC, or with the Secretary of the Department of Health and Human Services. To file a complaint with this facility, please contact the Administrator. To file a complaint with TSLC, please contact TSLC's Privacy Officer indicated below. All complaints must be submitted in writing directly to these individuals. We assure you that there will be no retaliation for filing a complaint.

VII. Sharing and Joint use of your Health Information

In the course of providing care to you and in furtherance of our mission to improve the health of the community, we will share your PHI with other organizations as described below who have agreed to abide by the terms described below:

A. Medical Directors: The medical director(s) of this facility and this facility participate together in an organized health care arrangement to deliver health care to you. Both this facility and the medical directors have agreed to abide by the terms of this Notice with respect to PHI created or received as part of delivery of health care services to you in this facility. Medical directors will have access to and use your PHI for treatment, payment and health care operations purposes related to your care. We will disclose your PHI to the medical directors for payment, treatment and health care operations.

B. Business Associates: We will use and disclose your PHI to business associates contracted to perform business functions on its behalf including TSLC, its parent who performs certain business functions for our facility. Whenever an arrangement between this facility and another company involves the use or disclosure of your PHI, that business associate will be required to keep your information confidential.

C. Membership in Trinity Health:
As a part of Trinity Health, a national Catholic health care system, TSLC, other nursing homes, hospitals, and health care providers in Trinity Health share your PHI for utilization review and quality assessment activities of Trinity Health. All members of Trinity Health have agreed to abide by this Notice in sharing your PHI.

D. Affiliations: TSLC is affiliated with Trinity Home Health Services (THHS) that is also owned by Trinity Health. TSLC will share your PHI with THHS for purposes of your treatment, payment and health care operations.

VIII. Additional Information

For further information regarding the issues covered by this Notice of Privacy Practice, please contact the Administrator.

XI. Changes to this Notice

We will abide by the terms of the Notice currently in effect. We reserve the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains. We will provide you with the revised Notice within 60 days following a material change, or at your first visit following the revision of the Notice.

E. More Stringent State and Federal Laws: The State law of Michigan is more stringent than HIPAA in several areas. State law is more stringent when the individual is entitled to greater access to records than under HIPAA and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. We will continue to abide by these more stringent state and federal laws. The federal laws include applicable Internet privacy laws, such as the Children's Online Privacy Protection Act and the federal laws and regulations governing the confidentiality and access of nursing home clinical records, and confidentiality of health information regarding substance abuse treatment.

In Michigan, residents have more rights of access to behavioral health information than under HIPAA. Minors in Michigan have more rights to confidentiality and protection of certain information (reproductive health, behavioral health and substance abuse) than under HIPAA.