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This notice describes how information about you may be used and disclosed and how you can get access to this information. Please Read It Carefully!

Notice Of Privacy Practices

Protected Health Information (PHI):


While receiving care from our facility, information regarding your medical history, treatment, and payment for your health care may be originated and/or received by us. Information which can be used to identify you and which relates to your medical care is protected by state and federal law ("Protected Health Information").

Your Rights


Federal law grants you certain rights with respect to your PHI. Specifically you have the right to:

  • Receive notice of our policies and procedures used to protect your PHI

  • Request that certain uses and disclosures of your PHI be restricted; provided however, we have the right to refuse your request.

  • Request that your PHI be amended

  • Obtain an accounting of certain disclosures by us of your PHI for the past six years

  • Revoke in writing any prior authorization for use of PHI, except to the extent that action has already been taken

  • Request communications of your PHI are done by reasonable alternative means or at alternative locations

Our Responsibilities


Federal law imposes certain obligations and duties upon us (the Sheffield Care Center) with respect to your PHI. Specifically, we are required to:

  • Provide you with notice of our legal duties and our facility's policies regarding the use and disclosure of your PHI

  • Maintain the confidentiality of your PHI in accordance with state and federal law

  • Review your requested restrictions regarding the use and disclosure of your PHI and inform you if these restrictions will be used

  • Allow you to inspect and copy your PHI during our regular business hours pursuant to any legal restrictions

  • Act on your request to amend PHI within sixty (60) days and notify you of any delay which would require us to extend the deadline (by the permitted thirty (30) day extension). Although this does not guarantee that amendment is appropriate

  • Accommodate reasonable requests to communicate PHI by alternative means or methods

  • Abide by the terms of this notice. 

In-Depth Information of our Privacy Practices

We respect the privacy of your personal health information and are committed to maintaining our resident's confidentiality. This notice applies to all information and records related to your care that our facility has received or created. It extends to information received or created by our employees, staff, volunteers, and physicians. This Notice informs you about the possible uses and disclosures of your personal health information. 


We are required by law to:

  • maintain the privacy of your protected health information

  • provide to you this detailed Notice of our legal duties and privacy practices relating to your personal health information

  • abide by the terms of the Notice that are currently in effect




You will be asked to sign an acknowledgement that you have received, reviewed, and understand this Notice. We have described the uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories.


For Treatment:  We will disclose you personal health information in providing you with treatment and services. We may disclose you personal health information to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, and physical therapists. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose personal health information to individuals who will be involved in your care after you leave the facility.


Payment: We may use and disclose you personal health information so that we can bill and receive payment for the treatment and services you receive at the facility. For billing and payment purposes, we may disclose your personal health information to your representative, insurance and managed care company, Medicare, Medicaid, or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.


For Health Care Operations: We may use and disclose you personal health information for the facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use personal health information to evaluate our facility's services, including performance of our staff.




Facility Directory: Unless you object, we will include certain limited information about you in our facility directory. This information may include your name, your location in the facility, and your general condition and your religious affiliation. Our directory does not include specific medical information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy.


Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may disclose your personal health information to a family member or close friend, including clergy, who is involved in your care. 


Disaster Relief: We may disclose your personal health information to an organization assisting in a disaster relief effort.


As Requested by Law: We will disclose your personal health information when required by law to do so.


Public Health Activities: We may disclose you personal health information for public health activities. These activities may include, for example:

  • reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting child abuse or neglect

  • reporting to the Federal Food and Drug Administration concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements

  • to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition

  • for certain purposes involving workplace illness or injuries.

Reporting Victims of Abuse, Neglect, or Domestic Violence: If we believe that you have been a victim of abuse, neglect, or domestic violence, we may use and disclose your personal health information to notify a government authority if required or authorized by law, or if you agree to the report.


Health Oversight Activities: We may disclose your personal health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections, and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.


Judicial and Administrative Proceedings. We may disclose you personal health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information.


Law Enforcement: We may disclose your personal health information for certain law enforcement purposes:

  • as required by law to comply with reporting requirements

  • to comply with a court order, warrant, subpoena, summons, investigative demand or similar legal process

  • to identify or locate a suspect, fugitive, material witness, or missing person

  • to report information about a suspicious death

  • to provide information about criminal conduct occurring at the facility

  • to report information in emergency circumstances about a crime

  • where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody

Research: We may allow personal health information of residents in our facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your personal health information may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board or Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.


Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations: We may release your personal health information to a coroner, medical examiner, funeral director, or (if you are an organ donor) to an organization involved in the donation of organs and tissue.


To Avert a Serious Threat to Health or Safety: We may use and disclose your personal health information when necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.


Military and Veterans: If you are a member of the armed forces, we may use and disclose your personal health information as required by military command authorities. We may also use and disclose personal health information about foreign military personnel as required by the appropriate foreign military authority.


Worker's Compensation: We may use or disclose you personal health information to comply with laws relating to work's compensation or similar programs.


Nations Security and Intelligence Activities; Protective Services for the President and Others: We may disclose personal health information to authorize federal officials conducting national security and intelligence activities or as needed to provide protection of the President of the United States, certain other persons or foreign heads of states or to conduct certain special investigations.




We will use and disclose personal information (other than as described in this Notice or required by law) only with your written authorization. You may revoke your authorization to use or disclose personal health information in writing, at any time. If you revoke your authorization, we will no longer use or disclose your personal health information for the purposes covered by the authorization, except where we have already relied on the authorization.






Right To Request Restrictions: You have the right to request restrictions on our use or disclosure of your personal health information for treatment, payment, or health care operations. You also have the right to restrict the personal health information we disclose about you to a family member, friend, or other person who is involved in your care or the payment for your care.


We are require to agree to your requested restrictions unless you're being transferred to another health care institution, the release of records is required by law, or the release of information is needed to provide you emergency treatment.


Right of Access to Personal Health Information: You have the right to request, either orally or in writing, your medical or billing records or other written information that may be used to make decisions about your care. We allow you to inspect your records within 24 hours of your request. If you request copies of the records, we must provide you with copies within 2 days of that request. We may charge a reasonable fee for our costs in copying and mailing your requested information.


We may deny your request to inspect or receive copies under limited circumstances. If you are denied access to personal health information, in some cases you will have a right to request review of the denial. This review would be performed by a licensed health care professional designated by the facility who did not participate inn the decision to deny.


Right to Request Amendment: You have the right to request the facility to amend any personal health information maintained by the facility for as long as the information is kept by or for the facility. You request must be made in writing and must state the reason for the requested amendment.


We may deny your request for amendment if the information:

  • Was not created by the facility, unless the originator of the information is no longer available to act on your request

  • Is not part of the personal health information maintained by or for the facility

  • is not part of the information to which you have a right to access

  • is already accurate and complete, as determined by the facility.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.


Right to an Accounting of Disclosures: You have the right to request an Accounting of our disclosures of your personal health information. This is a listing of certain disclosures of your personal health information made by the facility or by others on our behalf, but does not include disclosures for treatment, payment, and health care operations or certain other exceptions. 


To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. An accounting will include, if requested: the disclosure date, the name of the person or entity that received the information and address, if known; a brief description of the information disclosed; a brief statement of the purpose of the disclosure or a copy of the authorization request; a certain summary information concerning multiple similar disclosures. The first accounting is provided within a 12-month period will be free; for further requests; we may charge you our costs.


Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this notice electronically. You may request a copy of the Notice at any time.




If you believe that your privacy rights have been violated, you may file a complaint in writing with the facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the facility, contact the Administrator. We will not retaliate against you if you file a complaint.




We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all personal health information already received and maintained by the facility as well as for all personal health information we receive in the future. We will post a copy of the current Notice in the facility as well as publicly on the facility's web page. In addition, we will provide a copy of the revised Notice to all residents by mail.




If you have any questions about this Notice or would like further information concerning your privacy rights, please contact:


Sheffield Care Center Facility Administrator:

Chris Ruger

100 Bennett Drive

Sheffield, IA 50475


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