​At The Leaves, the confidentiality of all information concerning patients is of the utmost

importance. The ethical standards upheld by Christian Science nurses and other staff come

from the teachings of Christian Science with its emphasis on the confidential relationship

between Christian Science nurse and patient, and Christian Science practitioner and patient.

Maintaining that confidentiality for your protection is a Federal law known as the Health

Insurance Portability and Accountability Act of 1996 (HIPAA).

This law requires that all organizations such as ours protect the privacy of patients in a variety

of ways. The Leaves adheres to the letter and spirit of this law. This notice describes how

information regarding the services you receive here may be used and disclosed to others.

Please review it carefully before signing it.

1. I understand that the use or disclosure of my protected health information (PHI) by The

Leaves will only be for the purpose of providing Christian Science nursing care to me,

obtaining payment for my care bills, and conducting the normal business of running the

facility. PHI refers to any information about me and my care needs, collected at The Leaves

or from others, deemed necessary to care for me properly. This information about me

includes: my name, address, telephone number, and the same information for my spouse or

close family member I designate; my date of birth, Social Security and Medicare numbers;

my church affiliation, my Christian Science practitioner’s name and phone number; any

copy of my Health Care Power of Attorney, including the name(s) of my agent(s) and my

preferences regarding care; and records regarding my care and billing records.

2. I understand that my health care information will be given to my Responsible Party, the

Christian Science practitioner, my insurance company, and Medicare (by law). In addition, 

I

authorize The Leaves to share my health care information with the following individuals:

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If there are more than three individuals who are authorized to receive my health care

information, I will ask them to call my Responsible Party.

3. I understand that, if I do not object in writing, The Leaves will share the fact that I am in the

facility with telephone callers who directly ask for me by name, and with visitors who arrive

and ask for me by name. The Leaves does not, however, disclose information regarding my

care or condition in response to these inquiries.

4. I understand that, for my protection, The Leaves will sign agreements with any business

associates (for example, its auditor) that would have a valid reason to disclose my PHI.

These agreements will include a promise that the business will not disclose any PHI in any

way not essential to the normal activities of their business.

5. For my further protection, I understand that I will be asked to sign specific authorization any

time The Leaves decides to disclose any of my PHI to other care providers if I am being

transferred to an alternate care facility, or to anyone else for purposes other than the

routine needs described above. The only exceptions to this would be for contact with legal

authorities.

6. I understand The Leaves expects me to bring any concerns about this policy, or The Leaves’

compliance with it, to the attention of The Leaves HIPAA Compliance Officers, Jennifer

Johnson or Leanne DeVey. I also have the right to file a formal complaint with

The Leaves HIPAA Compliance Officer(s) and/or with the Federal agency, the Department of

Health and Human Services, if I feel that there has been a violation of these privacy rights.

The Leaves will not retaliate against me if I feel the need to file a complaint.

7. I understand that I have the right to review the complete HIPAA Privacy Policy of The Leaves

which is always available at the Business Office. This policy describes the types of uses and

disclosures of my PHI that may occur in the course of my stay at The Leaves. I may inspect,

copy, or amend my PHI.