Good Shepherd, Inc. is committed to respecting your privacy and protecting your personal information by following responsible information handling practices in keeping with privacy laws.

You can access our web site, http://www.goodshepherd-inc.com without disclosing your personally identifiable data.

We do use statistics tracking tools to measure usage information of the website. These tools do not collect, store or retrieve personally identifying information and is used solely to track performance and make improvements to the website.

GOOD SHEPHERD HEALTH CENTER, INC.
ACKNOWLEDGEMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES

GOOD SHEPHERD HEALTH CENTER, INC. NOTICE OF PRIVACY PRACTICES

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

GOOD SHEPHERD HEALTH CENTER, INC. uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of GOOD SHEPHERD HEALTH CENTER, INC.

How GOOD SHEPHERD HEALTH CENTER, INC. May Use or Disclose Your Health Information

For Treatment. GOOD SHEPHERD HEALTH CENER, INC. may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you respond to the actions.

For Payment. GOOD SHEPHERD HEALTH CENTER, INC. may use and disclose your health information to others for purpose of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.

For Health Care Operations. GOOD SHEPHERD HEALTH CENTER, INC. may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

• evaluate the performance of our staff;
• assess the quality of care and outcomes in your cases and similar cases;
• learn how to improve our facilities and services; and
• determine how to continually improve the quality and effectiveness of the health care we provide.

Appointments. GOOD SHEPHERD HEALTH CENTER, INC. may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Fund Raising. GOOD SHEPHERD HEALTH CENTER, INC. may use your information to contact you to raise funds for GOOD SHEPHERD HEALTH CENTER, INC.

Identification for Visitors. GOOD SHEPHERD HEALTH CENTER, INC. may post your name with your room number by the hallway door to your residence. GOOD SHEPHERD HEALTH CENTER, INC. may provide your name and room number to visitors and volunteers upon request.

Newsletter. GOOD SHEPHERD HEALTH CENTER, INC. may note your date of admit, discharge and birth in the regularly printed newsletter mailed to residents, tenants, family members, Telephone Reassurance subscribers, and interested community citizens.

Required by Law. GOOD SHEPHERD HEALTH CENTER, INC. may use and disclose information about you as required by law. For example, GOOD SHEPHERD HEALTH CARE, INC. may disclose information for the following purposes:

• for judicial and administrative proceedings pursuant to legal authority;
• to report information related to victims of abuse, neglect or domestic violence; and
• to assist law enforcement officials in their law enforcement duties;
• data as required by the Department of Human Services and the Iowa Foundation for Medial Care.

Public Health. Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

Decedents. Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donation. Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes if so designated by you.

Research. GOOD SHEPHERD HEALTH CENTER, INC. may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

Health and Safety. Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions. Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

Workers' Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers' Compensation.

Other uses. Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent GOOD SHEPHERD HEALTH CENTER, INC has taken action in reliance on such.

Your Health Information Rights
You have the right to:

• request a restriction on certain uses and disclosures or your information as provided by 45 C.F.R. §164.522: however, GOOD SHEPHERD HEALTH CENTER, INC. is not required to agree to a requested restriction;
• obtain a paper copy of the notice of information practices upon request;
• inspect and obtain a copy of your health record as provided for in 45 C.F.R § 164.524;
• request that your health records be amended as provided in 45 C.F.R. § 164.526;
• request communications of your health information by alternative means or at alternative locations; and
• receive an accounting of disclosures made of your health information as provided by 45 C.F.R. § 164.528.

Complaints

You may complain to GOOD SHEPHERD HEALTH CENTER, INC. and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

Obligation of GOOD SHEPHERD HEALTH CENTER, INC.

GOOD SHEPHERD HEALTH CENTER, INC. is required by law to:

• maintain the privacy of protected health information;
• provide you with this notice of its legal duties and privacy practices with respect to your health information;
• abide by the terms of this notice;
• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
• accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and

GOOD SHEPHERD HEALTH CENTER, INC. reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you by during Care Review Conferences or by mail.

Contact Information

If you have any questions or complaints, please contact;

GOOD SHEPHERD HEALTH CENTER, INC. (PRIVACY OFFICER)
302 Second Street NE
Mason City, IA 50401
Phone: (641) 424-1740

Disclosing Protected Health Information as Required by Law

Purpose
A covered entity may use or disclose protected health information to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law. This policy is designed to give guidance and ensure compliance with all relevant laws and regulations when using or disclosing protected health information as required by law.

Policy

1. If federal, state, and/or local law requires a use or disclosure of protected health information, GOOD SHEPHERD HEALTH CENTER, INC. may use or disclose protected health information to the extent that the use or disclosure complies with such law and is limited to the requirements of such law.
2. GOOD SHEPHERD HEALTH CENTER, INC. will refer to specific policies and procedures to determine whether or not GOOD SHEPHERD HEALTH CENTER, INC. must obtain authorization, or give the individual the opportunity to agree or object to use of disclose protected health information.
3. In the event that two or more laws or regulations governing the same use or disclosure conflict, GOOD SHEPHERD HEALTH CENTER, INC. will comply with the more restrictive laws and regulations.

Procedures

1. GOOD SHEPHERD HEALTH CENTER, INC. may use or disclose protected health information to the extent that such use or disclosure is required by law including, but not limited to:
   • For public health activities required by law;
   • For disclosures about victims of abuse, neglect, or domestic violence;
   • In order to comply with judicial release;
   • To comply with law enforcement;
   • For health release;
   • To avert a serious threat to health or safety;
   • To comply with special government functions or requests.
2. When disclosing protected health information in accordance with procedure #1, GOOD SHEPHERD HEALTH CENTER, INC. will follow the policies and procedures relating to the applicable policy.
3. Personnel receiving a request from an individual or entity for use or disclosure of protected health information will utilize files, reports and electronic data to determine whether the requesting individual is a person with whom GOOD SHEPHERD HEALTH CENTER, INC. has a knowing relationship.
4. Personnel will follow appropriate policies and procedures for verifying the identity and authority of individuals requesting protected health information.
5. Once it is determined that use or disclosure is appropriate, Medical Records personnel with appropriate access clearance will access the individual's health information using proper access and authorization procedures.
6. The requested protected health information will be delivered to the individual in a secure and confidential manner, such that the information cannot be accessed by employees or other persons who do not have appropriate access clearance to that information.
7. Medical Records personnel will appropriately document the request and delivery of the protected health information.
8. In the event that the identity and legal authority of an individual or entity requesting protected health information cannot be verified, personnel will refrain from disclosing the requested information and report the case to the Privacy Officer in a timely manner.

Knowledge of a violation or potential violation of this policy must be reported directly to the Privacy Officer, President/CEO or Administrator.