Effective Date: September 23, 2013

Protecting Your Information

Covenant Woods is committed to maintaining the privacy of all resident information and adheres to the requirements of the Health Insurance Portability and Accountability Act. The Privacy Practices Statement explains the way in which Covenant Woods safeguards each resident’s protected health information. If you have questions, or comments, please contact the Compliance Officer, Erik Mauritsen, at 804-569-8002 or via email


The continuing care of retirement facilities and services offered herein are offered solely by Covenant Woods Corporation, a VA corporation, which is not affiliated with any outside continuing care retirement facility or provider.

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We respect the privacy of your personal health information and are committed to maintaining our residents’ privacy and confidentiality. This Notice applies to all information and records related to your care that our facility has received or created. We need these records to provide you with quality care and to comply with certain legal requirements. It extends to information received or created by our employees, staff, volunteers and medical director. 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 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; and
Abide by the terms of the Notice that are currently in effect.
How Covenant Woods may use and disclose health information about you
The following categories describe different ways that we use and disclose health information. Following each use or disclosure, there will be a brief description further explaining it. All of the ways we are permitted to use and disclose information will not be listed, but will fall within one of these categories.

For Treatment. We may use health information about you to provide you with health care treatment and services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at Covenant Woods, at the hospital if you should be hospitalized while a resident at Covenant Woods, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

For Payment. We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you.

For Health Care Operations. We may use and disclose health information about you for the operations of our retirement community. These uses and disclosures are necessary to run our community and make sure that all of our residents receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many residents to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements.

Research. Under certain circumstances, we may wish to use and disclose health information about you for research purposes. If this is the case, we will request ahead of time that you sign an authorization form allowing us to use and disclose this information. If you wish not to participate, you can let us know at that time.

As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.

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

Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following:

to prevent or control disease, injury or disability;
to report births or deaths;
to report abuse or neglect;
to report reactions to medications or problems with products;
to notify people of recalls of products that may be using;
to notify person or organization required to receive information on FDA-regulated products;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
to notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if the efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release health information if asked to do so by a law enforcement official:

in reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime;
in response to a court order, subpoena, warrant, summons or similar process;
to identify or locate a suspect, fugitive, material witness, or missing person:
-Name and address;

-Date of birth or place of birth;

-Social security number;

-Blood type or rh factor;

-Type of injury;

-Date and time of treatment and /or death, if applicable; and

-A description of distinguishing physical characteristics.

about the victim of a crime, if the victim agrees to disclosure or under certain limited circumstances, we are unable to obtain the person’s agreement;
about a death we believe may be the result of criminal conduct;
about criminal conduct at our facility; and
in emergency circumstances to report a crime; the location of a crime or victims; or the identity, description, or location of the person who committed the crime.
Coroner, Health Examiners and Funeral Directors. We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about residents to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities.

Marketing and Sale of Personal Health Information. We must receive your written authorization for any disclosure of personal health information for marketing purposes or for any disclosure which is a sale of personal health information.

Not Otherwise Permitted. In any other situation not described above, we may not disclose your personal health information without your written authorization.

Your rights regarding health information about you
You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. This includes health and billing records, but not psychotherapy notes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the clinic and submit it to the clinic nurse who will take the proper steps to grant the request. If you request a copy of the information, we will charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed by making the request in writing. Your request will then be reviewed by the Compliance Officer and the clinic nurse will comply with the outcome of the review.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, you must submit your request in writing and submit your request to the clinic nurse.

We may deny your request if you ask us to amend information that:

was not created by us, unless that person or entity that created the information is no longer available to make the amendment;
is not part of the health information kept by or for our community;
is not part of the information which you would be permitted to inspect and copy; or
is accurate and complete.
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosure of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations as previously described.

To request this list of disclosures, you must submit your written request to the clinic nurse. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not exceed a total of 60 days from the date you made the request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must submit a written request to the clinic. The request will require the information you want to limit and to whom you want the limits to apply.

Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your personal health information to a health plan if the personal health information pertains to health care services or items for which you or anyone other than your health plan paid in full.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.

To request confidential communications, you must submit a written request to the clinic. We will not ask you the reason for the request and we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured personal health information.

Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from the Compliance Officer.

You may also obtain a copy of this notice either from the front desk at Covenant Woods, our website (, or by requesting a copy of this notice be sent through email to If we know that the electronic message has failed to be delivered, a paper copy of this notice will be provided. Even if you have received a copy electronically, you still retain the right to receive a paper copy upon request.

III. Changes to This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on each page, in the top left-hand corner, the effective date. In addition, each time you register for treatment or healthcare services, we will offer you a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the Compliance Officer. All complaints must be submitted in writing to the clinic. You will not be penalized for filing a complaint.

Other Uses of Health Information
Other uses and disclosure of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission by written request to the clinic, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Acknowledgment of Receipt of Notice
Upon admission to Covenant Woods, we will ask you to sign an acknowledgment that you received this Notice. If you choose, or are not able to sign, a staff member will complete the acknowledgement form by signing their name. The acknowledgement will be filed with your records.