NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION - April 15, 2003

Springdale is required by law to protect the privacy of your healthcare information. It will keep confidential any and all resident healthcare information and will provide residents with a list of duties or practices that protect confidential healthcare information.

Your confidential healthcare information may be released to other healthcare professionals within Springdale for the purpose of providing you with quality healthcare.

Your confidential healthcare information may be released to your insurance provider for the purpose of Springdale receiving payment for providing you with needed healthcare services.

Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.

Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).

Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.

Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice.

You may revoke your permission to release confidential healthcare information at any time.

You have the right to receive confidential communication about your health status.

You have the right to restrict the use of your confidential healthcare information. However, Springdale may choose to refuse your restriction if it is in conflict with providing you with quality healthcare, or in the event of an emergency situation.

Your confidential healthcare information may be released for marketing, fundraising or medical research purposes, only after receiving written authorization from you.You have the right to make changes to your healthcare information.

You have the right to know who has accessed your confidential information and for what purpose, other than for treatment, payment and healthcare operations.

Springdale will abide by the terms of this notice. Springdale reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information. Residents will receive a mailed copy of any changes to this notice within 60 days of making the changes.

You may be contacted by Springdale to remind you of any appointments, healthcare treatment options or other health services that may be of interest to you.

You have the right to review and photocopy any/all portions of your healthcare information.

You have the right to possess a copy of this Notice of Privacy Practice. This copy can be in the form of an electric submission or on paper.

You have the right to complain to Springdale if you believe your rights to the privacy of your health information have been violated.

All complaints will be investigated. No personal issues will be raised for filing a complaint with Springdale.

I hereby acknowledge that I have received a copy of Springdale’s Notice of Privacy Practices:

Resident’s Name__________________________________________________________________

Responsible Party’s Name___________________________________________________________

Date _________________