Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated


Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds


Our Uses and Disclosures

We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions


We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. For more information visit: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.


Your Rights As a Patient/Resident


Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.


Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.


Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.


Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.


Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.


Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.


Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.


File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us at (585) 350-5551

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting http://www.hhs.gov/ocr/ privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.


Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the saturations described below, talk to us. Tell us what you want us to do and we will follow your instructions.


You have the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety


In these cases, we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes


In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.


Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.


Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.


Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.


Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services


How else can we use or share your health information? We are allowed or required to share your

information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html


Help with public health and safety issues

• We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety


Do research

• We can use or share your information for health research.


Comply with the law

•We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal

privacy law.


Respond to organ and tissue donation requests

• We can share health information about you with organ procurement organizations.


Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.


Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

•For special government functions such as military, national security, and presidential protective services


Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.


Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know if a breach occurs that may have compromised the privacy or security of your information.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.


Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. Please inquire with our staff if you have any questions.


Anti-Discrimination Disclaimers

Our organization and its facilities do not discriminate in the admission, retention or care given to patients/residents in terms of age, race, creed, color, national origin, gender, gender identity, marital status, sexual preference, handicap, blindness, disability or sponsor.


Our organization is an Equal Opportunity Employer (EOE) and considers all candidates for employment regardless of race, color, age, sex, sexual orientation, genetic history, national origin, marital status, disability, Vietnam or disabled veteran status or arrest record.


Maximum rates for residency and services

In no event shall a resident be charged more than $1,000 per day for residency and/or services.


Bishop


Aetna

Skilled Level 1 – 280

Comprehensive Level 2 – 280

Complex Level 3 – 458

Level 4 – 570


Excellus

Medicare/Commercial:

Level 1 – 297.95

Level 2 – 361.21

Level 3 – 404

Level 4 - 675

Medicaid:

Level 1 – 235

Level 2 – 325

Level 3 – 375

Level 4 – 675

MLTC – 234.15


Fidelis

Medicare:

Level 1 – 235.97

Level 2 – 350

Level 3 – 425

MLTC – 234.15

Medicaid:

Level 1 – 235.97

Level 2 – 350

Level 3 – 425

Custodial – 235.97


Hospice

Non-core – 6.50


Humana

Level 1 – 345

Level 2 – 415

Level 3 – 590

Level 4 – 700


iCircle – 257.57


Molina

Custodial – 235.97

Medicaid only Level 1 – 235.97

Level 2 – 235.97

Level 3 – 235.97

Vent – 235.97


Tricare


United Healthcare – 234.15

Medicaid – 295

Medicare/Commercial – 400

Optum:

Part A – 385/mo


VA CCN - PDPM


VNA (Nascentia)

MLTC – 234.15


VNS

MLTC – 234.15


Wellcare/Today’s Opt

MLTC – 234.15

Medicare/Medicaid:

Level 1 – 228

Level 2 – 280

Level 3 – 350

Level 4 – 400

Level 5 – 600



Chautauqua


Aetna

Subacute Level 1 – 260

Comprehensive Level 2 – 345

Complex Level 3 – 385

Intensive Level 4 – 515


BCBS

Skilled Level 1 – 233.40

Subacute Level 2 – 302.36

Res Custodial – 198.97

Bedrest – 99.49


Humana

Level 1 – 345

Outpatient Level 4 – 700


iCircle

Skilled Nursing – 350

MCR & Managed MCD Subacute Therapy – 400

MCR & Managed MCD Subacute Rehab – 450

MCR & Managed MCD Respite Care – 295

MCR & Managed MCD Skilled Nursing – 350

MCR & Managed MCD Subacute Therapy – 400

MCR & Managed MCD Subacute Rehab – 450

MCR & Managed MCD Respite Care – 295


IHA

Nursing – 270


Kalos

MLTC – 234.56


MVP Health

Skilled Nursing – 210

Rehab Nursing – 300

Rehab Nursing – 350

Rehab Nursing – 450


Nascentia Health VNA

Skilled Nursing – 234.56


United Healthcare

Skilled – 355

UHC Commercial Skilled - 365

Skilled Nursing – 237


Univera

Skilled – 250

Med Adv & Commercial Subacute – 340

Subacute-Rehab – 375


UPMC Health – PDPM


Wellcare

MLTC – 234.56

Medicare Adv & Medicaid Level 1 – 290

Level 2 – 340

Level 3 – 395

Level 4 – 440

Level 5 – 600



Roscoe


ArchCare MLTC

Medicaid – 224.33

Managed Medicaid – 222.34

Custom – 234.32

Custom – 236.28


Fidelis

Medicaid Custodial – 236.28

Medicaid MLTC – 234.32

Medicaid/Medicare Skilled Level 1 – 225

Level 1 – 325

Level 3 – 425


Hamaspik

Medicaid Managed – 236.28

Medicaid MLTC – 234.32

Medicaid/Medicare Level 1 – 300

Level 2 – 375

Level 3 – 450

Level 4 – 600


iCircle MLTC – 259.91/257.75


Medicaid – 224.33/222.34


Medicaid Pending

Semi – 280.64

Private - 296.76


Medicare PDPM


MVP

Managed MCD/Respite Custodial – 224.33

Medicaid/Commercial Level 1 – 291

Medicaid/Commercial Level 2 – 351

Medicaid/Commercial Level 3 – 456

Medicaid/Commercial Level 4 – 501

Medicare MCR – PDPM


No Fault & WC PDPM


Private Pay

Semi – 280.64

Private – 296.76


United Healthcare (no Optum)

Medicaid Custodial – 275

Medicare/Commercial Skilled – 352

Medicare/Commercial Trach – 450


VA CCN – PDPM


VNS MLTC – 236.28/234.32



Sunset


Aetna Level 1 – 275

Level 2 – 350

Level 3 – 450

Level 4 – 550

Level 5 – 625


CDPHP


Excellus

Level 1 – 175

Medicare/Commercial Level 2 – 215

Level 3 – 285

Level 4 – 198


Fidelis

MLTC – 171.92

All Types Custodial – 160

Level 1 – 250

Level 2 – 300

Level 3 – 350


GHI

Level 1 – 275

PPO Level 1 – 375

Level 2 – 500

Level 3 – 550


HMO

Level 1 – 250

Level 1 – 350

Level 2 – 450

Level 3 – 500


Medicaid

Level 1 – 240

Level 1 – 330

Level 2 – 425

Level 3 – 475


No Fault & WC PDPM


MVP

Level A – 260

Medicare/Medicaid Level B – 275

Level C – 300

Level D – 350


NYSCHP


Private Pay

Semi – 304.31

Private – 327.72


SNH – 171.92


Tricare


United Health Care

Medicare/Commercial Skilled – 336

Medicaid Skilled – 250

Medicaid Custodial – 156.62

Optum Skilled – 214/246/327/475


Wellcare

Level 1 – 275

Medicare/Medicaid Level 2 – 300

Level 3 – 350

Level 4 – 400

Level 5 – 575

LT/Custodia. – 171.92



Susquehanna


Aetna

Commercial:

Level 1 – 200

Level 2 – 260

Level 3 – 350

Medicare:

Level 1 – 210

Level 2 – 270

Level 3 – 360


CDPHP

MLTC – 204

Skilled MC – 233

Medicare – 265

Gov – 324


Excellus

Skilled – 287.95

Medicare/Commercial Subacute – 361.21

Subacute Rehab – 404

Vent/TBI – 675

Medicaid/Special:

Skilled – 235

Subacute 325

Subacute Rehab – 375

Vent/TBI – 675

Custodial – 219.03

Respite – MCD Rate


MVP

Level 1 – 260

Level 2 – 325

Level 3 – 420

Level 4 – 490


Fidelis

Medicaid Custodial MLTC – 219.03

Medicaid custodial MLTC – 220.84

MCD/MCR Skilled Level 1 – 235

Level 2 – 300

Level 3 – 350

Level 4 – 450


Humana

Level 1 – 345

Choice Care Level 2 – 415

Level 3 – 590

Level 4 – 700


iCircle MLTC

Custodial – 240.93

MLTC & Managed MCD Custodial – 242.92

MLTC & Managed MCD Skilled – 350

MLTC & Managed MCD Subacute Therapy – 400

MLTC & Managed MCD Subacute Rehab – 450

Medicare Skilled – PDPM


Medicaid – 233/212.10


Medicaid Pending

Semi - 233

Private – 212.10


Medicare – PDPM


No Fault & WC – PDPM


Private Pay

Semi – 350

Private 360


United Healthcare

Optum – 365

Medicaid – 233

MCR/Commercial Skilled – 342

MCR/Commercial Bariatric – 382

MCR/Commercial Trach – 410


VA CNN – PDPM


Veterans

Bed Hold – 221.61

Rehab + Extensive – 469

Rehab – 381

Extensive – 422

Special Care – High – 350

Special Care – Low – 330

Clinically Complex 288

Psychosocial – 253

Reduced Physical Functions – 253


FacilityOwnersLandlordLandlord Address
Clinton Square Operations, LLCEdward Farbenblum, Orly LiebermanClinton Square Realty Holdings LLCc/o Amalgamated Realty LLC
2537 Route 52, Suite 18
Hopewell Junction, New York 12533
Dunkirk Operating LLCEdward Farbenblum, Anthony Bacchi, Isaac Hersh, Deena HershDunkirk Realty Holdings LLCc/o Amalgamated Realty LLC
2537 Route 52, Suite 18
Hopewell Junction, New York 12533
Roscoe Regional Healthcare, LLCEdward Farbenblum, Orly LiebermanRoscoe Regional Holdings, LLCc/o Amalgamated Realty LLC
2537 Route 52, Suite 18
Hopewell Junction, New York 12533
Sunset Nursing & Rehabilitation Center, Inc. Mary Katherine Mathis, Jeremy L. Britton, Edward Farbenblum, Aharon Bleier, Joel Schwartz, Orly Lieberman, Jason NewmanSunset Propco LLCc/o Amalgamated Realty LLC
2537 Route 52, Suite 18
Hopewell Junction, New York 12533
Susquehanna Nursing & Rehabilitation Center LLCAnthony Bacchi, Tibor Lebovich, Julia Vinocurova, Alex Berger, Edward FarbenblumSUSQUEHANNA REALTY, LLCc/o Amalgamated Realty LLC
2537 Route 52, Suite 18
Hopewell Junction, New York 12533

Summary of all contracts for the provision of goods and services for which the facility pays with any portion of Medicaid or Medicare funds or other agreements entered by the facility within 30-days of execution:

255 Greenwich Medical ServicesPodiatry
255 Greenwich Medical ServicesDermatology
AirgasO2 Tanks
AllscriptsAdmissions referral system
AMTDME
ARJOPM program
Bates TroyLinen Service
Bates TroyLinen Services - rental
BMALicensed Under the Broadcast Music
Broome County DSSHome Health
Central Solutions StaffingStaffing - Dietary
CHEPsychological Services
Claimex LLCCollections
Dedicated Nursing AssociatesStaffing - Nursing
Delta HealthHome Care Scheduling Program
DentServDental
Eastern Managed PrintCopier/Fax
EcolabDish Machine
ElevateittElevator Service
Ferguson ElectricElectrical Services
Great Lakes Building SysLife Safety Systems
Guardian Consulting ServicesPharmacy Consultant
Health Care Services GroupHousekeeping/Laundry Contract Services
Health Care Services GroupMaintenance Services
Health System ServicesPart B Supplies - Enterals, wound care, trach, ostomy, urologic
Healthcare StaffigStaffing - nursing
Healthcare StaffingStaffing - Nursing
HealtheConnectionsHealth Information Exchange
HealthlinknyPHI
HealthStream - RenewalAbaqis
ILS Community NetworkMLTC
Infinity Medical SolutionsRentals & Disposals
Integrity Cost ConsultingAudit Telephone and Waste Expenses
Johnson ControlsLife Safety Systems
JW DanforthPlumbing/HVAC Services
Kinney ServicesExclusion Checking
Lucent Group LLCDietary Contracted Services
Luzon EnvironmentalUST Service
Marywood UniversityRD Students
MealTrackerMenu
MedlineSupplies and Abaqis
MedlineSupplies PPD
MedServEye Care
Norton Nursing ServicesStaffing
Nova Healthcare SolutionsConsulting Services Agreement
Nurse Connection StaffingStaffing - Nursing
Otis ElevatorElevator Service
Patient Care AssociatesPortable X-Ray
Penn PowerGenerator Service
PharmscriptPharmacy
Premier Medical EquipmentEquipment Rental - Negative Pressure Wound Therapy
Premier Rebate ACHRebate Direct Deposit
ProcarePharmacy
ProValidusStaffing - Nursing
Rogers Service GroupRecord Storage
Scent AirEnvironmental Scent
StericycleMedical Waste Disposal
Summit Health CareMedicaid Applications
SUNY BinghamtonSocial Work Interns
Support Care PsychologyPsychiatric Services
Tembo Health (Simple Access)Medical Management Services
TK ElevatorElevator Service
TotalKareWanderguard system
TwomagnetsStaffing - Nursing
UHS Medical DirectorMedical Director/Physician Services
UNSBuilding System Controls
US BankCopier/Fax
Vohra Wound PhysiciansMedical Director/Physician Services

BISHOPCHAUTAUQUAROSCOESUNSETSUSQUEHANNA
AETNAAETNAArchCare MLTCAetnaAetna
EXCELLUSBCBSFidelisCDPHPCDPHP
FidelisHUMANAHamaspikExcellusExcellus
FidelisiCIRCLEiCircle MLTCFidelisMVP
HospiceIHAMVPGHIFidelis
HumanaKALOSUnited Healthcare (no Optum)MVPHumana
iCircleMVP HEALTHVA CCNNYSCHPiCircle MLTC
MolinaNASCENTIA HEALTH vnaVNS MLTCSNHUnited Healthcare
TricareUNITED HEALTHCARETricareVA CCN
United HealthcareUNIVERAUnited HealthcareVeterans
VA CCNUPMC HEALTHOptum
VNA (Nascentia)WELLCAREWellcare
VNS
Wellcare/Today's Opt