Nursing Home Disclosure Information

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

$599 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 – 287.95

Level 2 – 361.21

Level 3 – 404

Level 4 - 675

Medicaid:

Level 1 – 235

Level 2 – 325

Level 3 – 375

Level 4 – 675

MLTC – 276.66

Fidelis

Medicare:

Level 1 – 274.57

Level 2 – 350

Level 3 – 425

MLTC – 276.66

Medicaid:

Level 1 – 274.57

Level 2 – 350

Level 3 – 425

Custodial – 274.57

Hospice

Non-core – 6.50

Humana

Level 1 – 395

Level 2 – 465

Level 3 – 640

Level 4 – 740

iCircle – 304.55

Molina

Custodial – 274.57

Medicaid only Level 1 – 274.57

Level 2 – 288.30

Level 3 – 302.03

Vent – 366.54

Tricare - 248

United Healthcare – 276.86

Medicaid – 309

Medicare/Commercial – 435

Optum Part A – 500 PMPM

VA CCN - PDPM

VNA (Nascentia

MLTC – 276.86

VNS

MLTC – 276.66

Wellcare/Today’s Opt

MLTC – 276.66

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

Amerigroup

Custodial - 236.24

Level 1 - 309.43

Level 2 - 365.25

BCBS

Skilled Level 1 – 235.61

Level 2 – 314.15

Subacute Level 3 - 392.69

Hospice - 249.19/246.99

Humana

Level 1 – 395

Level 2 - 465

Level 3 - 640

Level 4 – 740

iCircle

MLTC - 287.36

MCR & Managed MCD Custodial - 287.36

MCR & Managed MCD Respite - 295

MCR & Managed MCD Skilled - 350

MCR & Managed MCD Subacute Therapy - 400

MCR & Managed MCD Subacute Rehab - 450

MCR & Managed MCD Skilled - PDPM

IHA - 310/375

Kalos

MLTC - 261.24

Medicaid - 249.19/246.99

Nascentia Health VNA

MLTC – 261.24

United Healthcare

Skilled – 248

UHC Commercial Skilled - 396

UHC MCR Advantage - 396

Optum (part A) $550 PMPM – 0.10

Univera

Skilled – 300

Med Adv & Commercial Subacute – 365

Med Adv & Commercial Subacute-Rehab - 410

Special Skilled - 275

Special Subacute - 350

Special Subacute-Rehab - 400

Medicaid Skilled - 254

Medicaid Subacute - 298

Medicaud Subacute-Rehab - 340

VA CCN - PDPM

Wellcare

MLTC – 261.24

Medicare Adv & Medicaid:

Level 1 – 290

Level 2 – 340

Level 3 – 395

Level 4 – 440

Level 5 – 600

Roscoe

Aetna

Level 1 - 245

Level 2 - 315

Level 3 - 360

ArchCare MLTC

Medicaid – 234.09

Managed Medicaid – 232.06

Custom – 245.08

Custom – 247.11

Excellus

Medicaid Managed - 245.08

Fidelis

Medicaid Custodial – 247.11

Medicaid MLTC – 245.08

Medicaid/Medicare Skilled:

Level 1 – 225

Level 2 – 325

Level 3 – 425

Hamaspik

Medicaid Managed – 247.11

Medicaid MLTC – 245.08

Medicaid/Medicare:

Level 1 – 300

Level 2 – 375

Level 3 – 450

Level 4 – 600

iCircle MLTC – 271.82/269.59

Medicaid – 234.09/232.06

Medicaid Pending

Semi – 280.64

Private - 296.76

Medicare - PDPM

MVP

Managed MCD/Respite Custodial – 234.09

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

United Healthcare (no Optum)

Medicaid Custodial – 275

Medicare/Commercial Skilled – 352

Medicare/Commercial Trach – 450

VA CCN – PDPM

VNS MLTC – 247.11/245.08

Sunset

Aetna

Level 1 – 275

Level 2 – 350

Level 3 – 450

Level 4 – 550

Level 5 – 625

CDPHP

Excellus

Medicare/Commercial:

Level 1 – 175

Level 2 – 215

Level 3 – 285

Level 4 – 198

Fidelis

MLTC – 196.46

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

Humana

Choice Care:

Level 1 - 395

Level 2 - 465

Level 3 - 640

Level 4 - 740

MVP

Medicare/Medicaid:

Level A - 260

Level B - 275

Level C - 300

:Level D - 350

No Fault & WC PDPM

NYSC & FC - 248

NYSCHP - 396

SNH – 196.46

Tricare

United Health Care

Medicare/Commercial Skilled – 336

Medicaid Skilled – 250

Medicaid Custodial – 156.62

Optum Skilled – 214/246/327/475

Wellcare

Medicare/Medicaid:

Level 1 – 275

Level 2 – 300

Level 3 – 350

Level 4 – 400

Level 5 – 575

LT/Custodial – 196.46

Susquehanna

Aetna

Commercial:

Level 1 – 200

Level 2 – 260

Level 3 – 350

Medicare:

Level 1 – 210

Level 2 – 270

Level 3 – 360

CDPHP

Skilled:

MLTC – 204

Skilled MC – 233

Medicare – 265

Gov – 324

Excellus

Medicare/Commercial:

Skilled – 287.95

Subacute – 361.21

Subacute Rehab – 404

Vent/TBI – 675

Medicaid/Special:

Skilled – 235

Subacute - 325

Subacute Rehab – 375

Vent/TBI – 675

Custodial – 240.55

Respite – MCD Rate

MVP

Level 1 – 260

Level 2 – 325

Level 3 – 420

Level 4 – 490

Fidelis

Medicaid Custodial MLTC – 240.55

Medicaid Custodial MLTC – 238.66

MCD/MCR Skilled:

Level 1 – 235

Level 2 – 300

Level 3 – 350

Level 4 – 450

Humana

Choice Care:

Level 1 – 395

Level 2 – 465

Level 3 – 640

Level 4 – 740

iCircle MLTC

Custodial – 264.61

MLTC & Managed MCD Custodial – 262.53

MLTC & Managed MCD Skilled – 350

MLTC & Managed MCD Subacute Therapy – 400

MLTC & Managed MCD Subacute Rehab – 450

Medicare Skilled – PDPM

Medicare – PDPM

No Fault & WC – PDPM

United Healthcare

Optum – 500 PMPM

Medicaid – 244

MCR/Commercial Skilled – 371

MCR/Commercial Bariatric – 411

MCR/Commercial Trach – 430

VA CNN – PDPM

Veterans

Bed Hold – 224.20

Rehab + Extensive – 570

Rehab – 435

Extensive – 550

Special Care – High – 396

Special Care – Low – 357

Clinically Complex - 307.41

Psychosocial – 264.56

Reduced Physical Functions – 276.72

VNA MLTC - 240.55/238.66

Wellcare

Custodial - 240.55

MCD/MCR:

Level 1 - 200

Level 2 - 280

Level 3 - 350

Level 4 - 400

Level 5 - 575