Walden Residential Centers Inc.

Privacy Policy


This notice describes how medical information may be used and disclosed and how residents can get access to this information.  Provided in compliance with 45C.F.R. 164.520

Health Record Information

When an individual is admitted to our facility, a record is created.  Typically this record contains symptoms, examinations, and test results, diagnosis, treatment and a plan for future care of treatment.  This medical record serves as a:

  • Basis for planning your care and treatment
  • Means of communication among the many health professionals who contribute to your care
  • Legal document describing the care you received
  • Means by which you or a third-party payer can verify the services billed were actually provided
  • A tool in educating health professionals
  • A source of data for medical research
  • A source of information for public health officials who oversee the delivery of healthcare in the United States
  • A source of data for facility planning and marketing
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

The resident, family and/or guardians are informed about what is in the medical record and how this health information is used.  This helps to ensure its accuracy, and the resident and guardian to better understand who, what, when, where, and why others may access the health information.  It also assists residents and guardians in making more informed decisions when authorizing disclosure to others.

Facility Responsibilities

The facility is required to:

  • Maintain the privacy of your health information
  • Provide you with a notice of our legal duties and Notice of Privacy Practices with respect to the information we collect and maintain about you
  • Abide by the terms of this policy
  • Notify the resident and/or guardian if we are unable to agree to a requested restriction *
  • Accommodate reasonable requests the resident, the family may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make to the new provisions effective for all protected health information we maintain.  Should our information practices be revised, residents and guardians will be notified

  1. Treatment– We will use our health information for treatment.  For example, information obtained by a nurse, physician or another member of the healthcare team will be recorded in your record and use to determine the course of treatment that should work best.  The attending physician will document in the record his or her expectations of the members of the healthcare team.  Members of the healthcare team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment.  We will also provide the physician or a subsequent healthcare provider with copies of various reports that should assist him or her with treating you when you are transferred from or discharged from our facility via the Authorization for the Release of Health Information.
  2. Payment– We will use your health information for payment.  For example, a bill may be sent to a third-party payer.  The information on or accompanying the bill may include information that identifies you, diagnosis, procedures, and supplies used.
  3. Health Care Operation-We will use your health information for regular health operations.  For example, members of the resident staff, facility resident care team (workforce), or the risk or quality improvement team, may use the information in the health record to assess the care and outcomes in your case and others like it.  This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare services we provide.
  4. Workforce– Facility’s workforce includes its employees, agent, and volunteers.
  5. Business Associates– There are some services provided in our organization provided through contacts with business associates.  Examples include our accountants, physicians and other medical consultants, therapists. Members of The Human Rights Committee, suppliers and attorneys.  When these services are contracted, we may disclose health information to our business associates so they can perform the job we’ve asked them to do.  To protect the health information, however, we require the business associates to appropriately safeguard information according to our Business Associate Agreement.
  6. Directory– Unless you and/or guardian notify us that he/she objects, we may use your name, location in the facility, general condition, and religious affiliation for directory purposes.  This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for the resident by name.
  7. Notification– We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition.  If we are unable to reach a family member or personal representative, then we may leave a message for them on the phone they have provided us, e.g. on an answering machine.
  8. Communication with Family– Health professionals, using their best judgment, may disclose to a family member, another relative, close personal friend or any other person identified by you, health information relative to that person’s involvement in your case or payment related to that care.
  9. Other Uses or Disclosures– Any uses or disclosures of your health information that are not addressed above shall only occur with the approval of the Administrator (Privacy Officer). Such other uses and disclosures may include, but are not limited to use and disclosure for the following purposes:


  1. As required by law
  2. For public health activities
  3.  About victims of abuse, neglect or domestic violence, such as reports to ODH
  4. For health oversight activities, such as surveys
  5. For judicial and administrative proceedings, such as in response to subpoenas
  6. For law enforcement purposes
  7. Notification of coroners
  8. Notification of funeral directors
  9. For cadaver organ, eye, or tissues donation purposes
  10. For research purposes
  11. To avert a serious threat to health or safety
  12. For specialized government functions, such as releases for military or veteran’s activities, national security or intelligence activities, or use by a prison
  13. For worker’s compensation
  14. Disclosures of de-identified information

10.   Consent for Treatment, Payment or Health Care Operations– The Facility shall only use or disclose a resident’s health information for treatment, payment or health care operation when it has a valid written consent from the resident or his/her legal guardian.  See the policy “Consent for the Use of Disclosure of a Client’s Health Information.”

11.  Access to Medical Record– All members of the Facility workforce and all Business Associates, shall have access to a resident’s entire medical record as needed, in order to accomplish their duties.

Health Information Resident Rights

Although your health record is the physical property of the facility, the information in the record belongs to you.  You and/or your legal guardian have the following rights:

  • To request that we not use or disclose health information for a particular reason related treatment, payment, the Facility’s general health care operations, and/or to a particular family member, other relative or close personal friend.  We ask that such requests be made in writing via the Request to Restrict Use or Disclosure of Health Information form.  Although we will consider your request, please be aware that we are under no obligation to accept it or abide by it.  For more information about this right, see 45Code of Federal Regulations (C.F.R.) 164.522 (a).
  • If you or your legal guardian is dissatisfied with the manner in which or the location where he/she is receiving communications from the Facility that are related to health information, he/she may request that we provide you with such information by alternative means or at alternative locations.  Such a request must be made in writing and submitted to the Administrator.  The Facility will attempt to accommodate all reasonable requests.  For more information about this right, see 45Code of Federal Regulations 45 C.F.R. 164.522 (b).
  • You or your legal guardian may request to inspect and/or obtain copies of health information about the resident, which will be provided to him/her in the time frames established by law.  Such requests must be made in writing via the Authorization for the Release of Health Information form.  Copies will be made available upon request with a reasonable fee. For more information about this right, see 45Code of Federal Regulations C.F.R. 164.524.
  • If you or your legal guardian believes that any health information in your record is incorrect or that important information is missing, he/she may request that the Facility correct the existing information or add the missing information.  Such requests must be made in writing and must provide a reason to support the amendment.  The Request for Amendment to Medical Records form provided by the Facility needs to be used to make such requests.  For a request form, please contact the Administrator (Privacy Officer).  For more information about this right, see 45 C.F.R. 164.526.
  • You or your legal guardian may request that the Facility provide a written accounting of all disclosures made by the Facility during the time period for which you request (not to exceed 6 years).  We ask that such requests be made via the Request for Accounting of Disclosures of Health

Information form.  Please note that this accounting will not apply to any of the following types of disclosures: disclosures made for reasons of treatment, payment, or health care operations; disclosures made to the resident or legal representative, or any other individual involved with the resident’s care; disclosures to correctional institutions or law enforcement officials; and disclosures for national security purposes.  No charge for the first accounting request in any 12-month period.  However, for any request made thereafter, a reasonable, cost-based fee will be charged.  For more information about this right, see 45 C.F.R. 164.528.

  • You or your legal guardian, have the right to obtain a paper copy of the Facility’s Privacy Protection Policy upon request.
  • You or your legal guardian may revoke an authorization to use or disclose health information, except to the extent that action has already been taken.  Such a request must be made in writing.

Contact Information

You or your legal guardian should direct any questions, requests, or concerns about health information rights or the Facility’s use and disclosure of health information, to the Privacy Officer.

The Administrator shall be responsible for overseeing the implementation, updating, and maintenance of this policy and procedure.