1. Eben Ezer Lutheran Care Center is permitted to use and disclosure protected health information for treatment, payment, and healthcare operations, including but not limited to the following examples:
   • For treatment- e.g., sending a fax to a physician regarding a resident’s condition
   • For payment- e.g., sending information about a resident to Medicare in order to obtain payment for services
   • For healthcare operations- e.g., sharing information about a resident at a care conference
2. Eben Ezer Lutheran Care Center is permitted or required, under specific circumstances, to use or disclose protected health information without the individual’s written authorization. This occurs when Eben Ezer is asked to provide information to a regulatory agency.
3. Other uses and disclosures will be made only with the Individual’s written authorization, and the individual may revoke such authorization.
4. Eben Ezer Lutheran Care Center intends to engage in the following activities:
   • Eben Ezer may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual or patient.
   • Eben Ezer may contact the individual/patient or his/her family to raise funds for Eben Ezer.
5. The Individual has the following rights regarding protected health information:
   • The right to request restrictions on certain uses and disclosures of protected health information. Eben Ezer is not required to agree to a requested restriction, however.
   • The right to receive confidential communications of protected health information, as applicable.
   • The right to inspect and copy protected health information, as provided in the Privacy Regulation.
   • The right to amend protected health information, as provided in the Privacy Regulation.
   • The right to receive an accounting of disclosures of protected health information.
   • The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically.

1. Eben Ezer is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.
2. Eben Ezer is required to abide by the terms of the Notice currently in effect.
3. Eben Ezer reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.
4. Eben Ezer will provide individuals or patients with a revised Notice in writing.
5. Individuals may complain to Eben Ezer, the Colorado Department of Public Health and Environment, and the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A brief description of how the individual may file a complaint follows:
   • The individual will contact the Eben Ezer Social Services Department or the other two agencies listed below and report the complaint.
   • The complaint will be documented in writing.
6. Eben Ezer’s contact office for matters relating to complaints is:
   Social Services Department
   970-842-2861
   Eben Ezer Lutheran Care Center
   122 Hospital Road
   Brush, CO 80723
7. Colorado Department of Public Health and Environment
   Health Facilities Division
   4300 Cherry Creek Drive South
   Denver, CO 80246-1530
   303-692-2800
8. The Department of Health and Human Services
   Secretary Tommy G. Thompson
   200 Independence Avenue, S.W.
   Washington, D.C. 20201
9. This Notice is first in effect on April 14, 2003.

Acknowledgement of the Privacy Notice

• I have the right to place restrictions on the way my protected health information is used or disclosed.
• I understand that Eben Ezer Lutheran Care Center is not required to agree with my requested restrictions. I also understand that once Eben Ezer agrees to my restrictions, it must comply with those restrictions.
• I have a right to revoke my consent for the use and disclosure of my protected health information at any time. I understand that, if I choose to revoke my consent, I must submit a written statement that is signed by me.
• I understand that Eben Ezer Lutheran Care Center must immediately comply with my request to revoke consent, except to the extent that it has already taken some action that was based on my original consent.
• Eben Ezer Lutheran Care Center has reserved the right to change from time to time our privacy practices that are described in the Notice of Privacy Practices. Whenever the practices are changed, the Notice will be modified accordingly; and I will be informed in writing.

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Signature