Notice of Privacy Practices


Memorial Home, Inc. dba Pine Village

Moundridge, Kansas




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 Pine Village has received or created. It extends to information received or created by Pine Village’s employees, staff, clergy, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your personal health information. It also describes your rights and our obligations regarding your personal health information.


We are required by the Health Insurance Portability and Accountability Act to:


Maintain the privacy of your protected health information;


Provide to you this detailed Notice of our legal duties, privacy practices and policies 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 of receipt of this notice allowing us to use and disclose your personal health information for purposes of treatment, payment and health care operations. We have generally described these uses and disclosures below and provide some examples of the types of uses and disclosures we may make in each of these categories. The examples provided are not meant to exhaustively list every possible use and disclosure that may be made.


For treatment. We will use and disclose your personal health information in providing you with treatment and services. We may disclose your personal health information to Memorial and non-Memorial personnel who may be involved in your care, such as physicians, nurses, nurse aides, ambulance personnel, emergency medical technicians, pharmacists, your designated agent for health care decisions and therapists. For example, a nurse caring for you will report any change in your condition to your physician. Additionally, we may disclose your personal health information to ambulance personnel, hospital personnel, a pharmacist, psychologist or psychiatrist that is involved in your care. We also may disclose personal health information to individuals who will be involved in your care after you leave Memorial, such as hospitals, ambulance personnel, emergency medical technicians, physicians, nurses, nurse aides, therapists and hospital administration officials.


For Payment. We may use and disclose your personal health information so that we can bill and receive payment for the treatment and services that you receive at Pine Village. For billing and payment purposes, we may disclose your personal health information to your agent for health care decisions, agent for financial decisions, an insurance or managed care company, Medicare, Medicaid or other third party payor and their authorized representatives. 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 your personal health information for Pine Village’s operations. These uses and disclosures are necessary to manage Pine Village and to monitor our quality of care. For example, we may use personal health information to: (1) conduct quality assessment and improvement activities, (2) review and evaluate the competence or qualifications of health care professionals, including our staff, (3) evaluate health plan performance, (4) conduct training programs, (5) train non-health care professionals, including volunteers, (6) obtain or renew accreditation, certification or licensing of the facility, (7) conduct or arranging for medical review, legal services, and audit functions with accountants, (8) conduct business planning and development, (9) various business management and general administrative activities.




Facility Directory. Unless you object, we will include certain limited information about you in our facility directory. This information may include your name, location in the facility, 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 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.


Resident Door Posting. Unless you object, we will place your name on a placard posted next to your door.


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 personal friend, including clergy, who is involved in your care. This will include, for example, your designated agent for health care decision making and all incidental disclosures to family members, friends, and clergy present in your room at the time of treatment, unless you manifest your objection to disclosure in their presence.


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


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


Public Health Activities. We may disclose your 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


  • Reporting to the Food and Drug Administration (FDA) 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 Exploitation (ANE). If we believe that you have been a victim of abuse, neglect or exploitation, we may use and disclose your personal health information to notify 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, our annual survey by the Department of Health and Environment, audits, investigations, 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 your personal health information in response to a subpoena, discovery request, or other lawful process. Efforts will be made to contact you about the request so that you may obtain an order or agreement protecting the information.


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


  • As required by law to comply with reporting requirements


  • To comply with a court order, warrant, subpoena, summons, investigative demand or similar process and To identify or locate a suspect, fugitive, material witness or missing person


  • When information is requested about the victim of a crime if the individual agrees or under other limited circumstances


  • 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 patients from our facility to be used or disclosed for research purposes provided that the researcher adheres to certain privacy protections. Your de-identified health information may be used for research purposes only if the privacy aspects of the research have been reviewed by the Memorial Health Information Management Office, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use of 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 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 your personal health information to comply with laws or insurance requirements relating to worker’s compensation or similar programs.


Fundraising Activities. We may use certain personal health information to contact you in an effort to raise money for the facility and its operations. We may disclose personal health information to a foundation related to the facility so that the foundation may contact you in raising money for the facility. In doing so, we would only release contact information, such as your name, address, phone number and the dates you received treatment or services at Pine Village.


Appointment Reminders And Test Results. We may use or disclose personal health information to remind you about an appointment or to inform you that test results are available.


Treatment Alternatives. We may use or disclose personal health information to inform you about treatment alternatives that may be of interest to you.


Health-Related Benefits and Services. We may use or disclose personal health information to inform you about health-related benefits and services that may be of interest to you.




We will use and disclose personal health 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.




You have the following rights regarding your personal health information at Pine Village:


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 the health care operation of Pine Village. You also have the right to restrict the personal health information we disclose about you to a family member, friend, designated agent for health care decision making or other person who is involved in your care or the payment for your care.


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


Right to Access to Personal Health Information. Your 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 must 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 the request. We may charge a reasonable fee for our costs in copying, mailing or delivering your requested information.


We may deny your request to inspect or receive copies in certain 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 Pine Village who did not participate in the decision to deny.


Right to Request Amendment. You have the right to request that Pine Village amend any personal health information maintained by us for as long as the information is kept by us. Your 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 Pine Village, 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 Pine Village;


  • Is not part of the information to which you have a right of access; or


  • Is already accurate and complete as determined by Pine Village.



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 your behalf, but does not include disclosures for treatment, payment, 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 14, 2003, that is within five 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 or request; or certain summary information concerning multiple similar disclosures. The first accounting provided within a 12-month period will be free; for further requests, a fee will be charged. No accounting provided will include a listing of incidental disclosures of your personal health information.


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 this Notice at any time. [You may obtain a copy of this Notice at our website:] It is also posted in the Main Entrance airlock and at other appropriate locations.


Right to Request Confidential Communications. You have the right to request that we communicate with you concerning personal health matters in a certain manner or at a certain location. For example – you can request that we contact you only at a certain phone number. We will accommodate your reasonable requests.




If you believe that your privacy rights have been violated, you may file a complaint 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: Shannon Phillips, HIPAA Privacy Officer, at (620) 345-2901. 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 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 at the main nurses station. In addition, we will provide a copy of the revised Notice to all residents by mailing the Notice with the next monthly billing statement.




Pine Village takes every effort to electronically protect your health information (EPHI) such as encrypting information before it is sent over the internet. All computer systems will require a password change every thirty (30) days.




If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Kim Sweely, HIPAA Privacy Officer, at (620) 345-2901 or