HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

January 1, 2014: NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Centre Crest is required by law t prvide yu with this ntice s that yu will understand hw we may use r share yur medical infrmatin. We are required t adhere t the terms utlined in this ntice. If yu have any questins abut this ntice, please cntact the Administratr. This ntice describes the practices f Centre Crest and its affiliates (tgether the affiliated cvered entity r Centre Crest ). Centre Crest is required by law t prvide yu with this ntice regarding ur legal bligatins with respect t yur prtected health infrmatin and t adhere t the terms f the ntice currently in effect. UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION Each time yu visit Centre Crest, a recrd f yur visit is made. Typically, this recrd cntains infrmatin abut yur cnditin and the treatment that we prvide. We use and/r disclse this infrmatin t: plan yur care and treatment cmmunicate with ther health prfessinals invlved in yur care dcument the care yu receive educate health prfessinals prvide infrmatin fr medical research prvide infrmatin t public health fficials evaluate and imprve the care we prvide Understanding what is in yur recrd and hw yur health infrmatin is used helps yu t: ensure it is accurate better understand wh may access yur health infrmatin make mre infrmed decisins when authrizing disclsure t thers HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The fllwing categries describe the ways that we use and disclse medical infrmatin. Nt every use r disclsure in a categry will be listed. Hwever, all f the ways we are permitted t use and disclse infrmatin will fall int ne f the categries. Fr Treatment. We may use medical infrmatin abut yu t prvide yu with medical treatment. We may disclse medical infrmatin abut yu t dctrs, nurses, therapists r ther Centre Crest facility persnnel wh are invlved in taking care f yu at Centre Crest. Ntice f Privacy Practices #3 revised december 9 2013 Page 1 f 8 Last printed 0/0/0000

Fr example, a dctr treating yu fr a brken leg may need t knw if yu have diabetes because diabetes may slw the healing prcess. In additin, the dctr may need t tell the dietitian if yu have diabetes s that we can plan yur meals. Different departments f Centre Crest facility als may share medical infrmatin abut yu in rder t crdinate yur care and prvide yu medicatin, lab wrk and x rays. We may als disclse medical infrmatin abut yu t peple utside the Centre Crest facility wh may be invlved in yur medical care after yu leave an Centre Crest facility. This may include family members, r visiting nurses t prvide care in yur hme. Fr Payment. We may use and disclse medical infrmatin abut yu s that the treatment and services yu receive at Centre Crest facility may be billed t yu, an insurance cmpany r a third party. Fr example, in rder t be paid, we may need t share infrmatin with yur health plan abut services Centre Crest prvided t yu. We may als tell yur health plan abut a treatment yu are ging t receive t btain prir apprval r t determine whether yur plan will cver the treatment. Fr Health Care Operatins. We may use and disclse medical infrmatin abut yu fr health care peratins. This is necessary t ensure that all f ur residents receive quality care. Fr example, we may use medical infrmatin t review ur services and t evaluate the perfrmance f ur staff. We may als cmbine medical infrmatin abut many Centre Crest residents t decide what additinal services Centre Crest shuld ffer, what services are nt needed, and whether certain new treatments are effective. We may als disclse infrmatin t dctrs, nurses, therapists, and ther Centre Crest persnnel fr review and learning purpses. We may remve infrmatin that identifies yu s thers may use it t study health care and health care delivery withut learning the identities f residents. OTHER ALLOWABLE USES OF YOUR MEDICAL INFORMATION The fllwing categries describe ther ways that we may use yur infrmatin. Business Assciates. There are sme services prvided in ur rganizatin thrugh cntracts with business assciates. Examples include medical directrs, utside attrneys and a cpy service we use when making cpies f yur health recrd. When these services are cntracted, we may disclse yur health infrmatin s that they can perfrm the jb we ve asked them t d and bill yu r yur third party payer fr services rendered. T prtect yur health infrmatin, hwever, we require the business assciate t apprpriately safeguard yur infrmatin. Prviders. Participants in ne f ur rganized healthcare arrangements ffer many services prvided t yu as part f yur care at ur facility. These participants include a variety f prviders such as physicians (egs. MD, DO, Pdiatrist, Dentist, Optmetrist), therapists (egs. Physical therapist, Occupatinal therapist, Speech therapist), prtable radilgy units, clinical labs, hspice caregivers, pharmacies, psychlgists, LCSWs, and suppliers (egs. prsthetic, rthtics). Treatment Alternatives. We may use and disclse medical infrmatin t tell yu abut Ntice f Privacy Practices #3 revised december 9 2013 Page 2 f 8 Last printed 0/0/0000

pssible treatment ptins r alternatives that may be f interest t yu. Health Related Benefits and Services. We may use and disclse medical infrmatin t tell yu abut health related benefits r services that may be f interest t yu. Fundraising Activities. We may use medical infrmatin abut yu t cntact yu in an effrt t raise mney as part f a fundraising effrt. We may disclse medical infrmatin t a fundatin related t Centre Crest s that the fundatin may cntact yu in raising mney fr Centre Crest. We will nly release cntact infrmatin, such as yur name, address and phne number and the dates yu received treatment r services at Centre Crest. Yu may request that we d nt cntact yu fr these fundraising effrts. If yu d nt want Centre Crest facility t cntact yu fr fundraising effrts, yu must ntify the Administratr in writing. Centre Crest Facility Directry. We may include infrmatin abut yu in the Centre Crest facility directry while yu are a resident s lng as we prvide yu an pprtunity t agree t, prhibit, r restrict the use f yur infrmatin. This infrmatin may include yur name, lcatin in Centre Crest facility, yur general cnditin (e.g., fair, stable, etc.) and yur religin. The directry infrmatin, except fr yur religin, may be disclsed t peple wh ask fr yu by name. Yur religin may be given t a member f the clergy, such as a priest r rabbi, even if they dn t ask fr yu by name. This is s yur family, friends and clergy can visit yu in the Centre Crest facility and generally knw hw yu are ding. Individuals Invlved in Yur Care r Payment fr Yur Care. We may disclse medical infrmatin abut yu t a friend r family member wh is invlved in yur care. We may als give infrmatin t smene wh helps pay fr yur care. Hwever, we can nly give family and friends infrmatin that relates t their invlvement r payment fr yur care. We may als tell yur family r friends yur cnditin and that yu are in Centre Crest. In additin, we may disclse medical infrmatin abut yu t an entity assisting in a disaster relief effrt s that yur family can be ntified abut yur cnditin, status and lcatin. As Required By Law. We will disclse medical infrmatin abut yu when required t d s by federal, state r lcal law. T Avert a Serius Threat t Health r Safety. We may use and disclse medical infrmatin abut yu t prevent a serius threat t yur health and safety r the health and safety f the public r anther persn. We wuld d this nly t help prevent the threat. Fr example, we may disclse medical infrmatin abut yu fr public health purpses, including: Preventin r cntrl f disease, injury r disability Reprting births and deaths; Reprting child abuse r neglect; Reprting reactins t medicatins r prblems with prducts; Ntice f Privacy Practices #3 revised december 9 2013 Page 3 f 8 Last printed 0/0/0000

Ntifying peple f recalls f prducts; Ntifying a persn wh may have been expsed t a disease r may be at risk fr cntracting r spreading a disease; Ntifying the apprpriate gvernment authrity if we believe a resident has been the victim f abuse, neglect r dmestic vilence. We will nly make this disclsure if yu agree r when required r authrized by law. Research. We may disclse infrmatin t researchers when an institutinal review bard that has reviewed the research prpsal and established prtcls t ensure the privacy f yur health infrmatin has apprved their research. Funeral Directrs, Crners and Medical Examiners. We may disclse health infrmatin t funeral directrs, crners and medical examiners t carry ut their duties cnsistent with applicable law. Organ prcurement rganizatins. Cnsistent with applicable law, we may disclse health infrmatin t rgan prcurement rganizatins r ther entities engaged in the prcurement, banking, r transplantatin f rgans fr the purpse f tissue dnatin and transplant. Fd and Drug Administratins (FDA). We may disclse t the FDA health infrmatin relative t adverse events with respect t fd, supplements, prduct and prduct defects, r pst marketing, surveillance infrmatin t enable prduct recalls, repairs, r replacement. Wrkers cmpensatin. We may disclse health infrmatin t the extent authrized by and t the extent necessary t cmply with laws relating t wrkers cmpensatin r ther similar prgrams established by law. Military and Veterans. If yu are a member f the armed frces, we may disclse medical infrmatin abut yu as required by military authrities. We may als disclse medical infrmatin abut freign military persnnel t the apprpriate freign military authrity. Health Oversight Activities. We may disclse medical infrmatin t a health versight agency fr activities authrized by law. These versight activities may include audits, investigatins, inspectins, and licensure. These activities are necessary fr the gvernment t mnitr the health care system, gvernment prgrams, and cmpliance with civil rights laws. Lawsuits and Disputes. If yu are invlved in a lawsuit r a dispute, we may disclse medical infrmatin abut yu in respnse t a curt r administrative rder. We may als disclse medical infrmatin abut yu in respnse t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made t tell yu abut the request r t btain an rder prtecting the infrmatin requested. Law Enfrcement. We may disclse medical infrmatin when requested by a law Ntice f Privacy Practices #3 revised december 9 2013 Page 4 f 8 Last printed 0/0/0000

enfrcement fficial: In respnse t a curt rder, subpena, warrant, summns r similar prcess; T identify r lcate a suspect, fugitive, material witness, r missing persn; Abut yu, the victim f a crime if, under certain limited circumstances, we are unable t btain the yur agreement; Abut a death we believe may be the result f criminal cnduct; Abut criminal cnduct at Centre Crest; and In emergency circumstances t reprt a crime; the lcatin f the crime r victims; r the identity, descriptin r lcatin f the persn wh cmmitted the crime. USES OF YOUR HEALTH INFORMATION THAT REQUIRE PRIOR AUTHORIZATION We must btain prir authrizatin frm yur prir t disclsing r using yur prtected health infrmatin fr certain purpses. Psychtherapy Ntes. We must receive prir authrizatin frm yu prir t using t disclsing yur psychtherapy ntes, unless the disclsure is fr treatment, payment r healthcare peratins, r is used fr ther very limited purpses. Marketing purpses. We must receive prir authrizatin frm yu befre disclsing yur medical infrmatin fr marketing purpses except in very limited circumstances. Sale f prtected health infrmatin. We must receive prir authrizatin frm yu befre selling yur prtected health infrmatin, except in limited situatins State Restrictins. Many states prvide greater prtectin fr certain types f health infrmatin. Fr example, in many states, drug and alchl treatment infrmatin may nly be released in limited circumstances. Additinally, HIV related infrmatin may nly be released in very limited situatins. Where the state requirements are mre stringent than federal requirements, we will cmply with the state requirements. OUR RESPONSIBILITIES WITH RESPECT TO YOUR MEDICAL INFORMATION We are required t maintain the privacy and security f yur prtected health infrmatin. In rder t fulfill these respnsibilities we must: Ntify yu prmptly if the privacy r security f yur health infrmatin has been cmprmised. Fllw the duties and privacy practices described in this ntice and give yu a cpy f it. Only use r share yur infrmatin as described in this Ntice unless yu authrize us in writing t use r share yur infrmatin in anther manner. If yu give us authrizatin, yu can change yur mind at any time. Hwever, if yu change yur mind, yu must infrm us in writing. If yu revke yur permissin, we will n lnger use r disclse medical infrmatin abut yu fr the reasns cvered by yur written authrizatin. Yu understand that we are unable t take back any disclsures we have already made with yur permissin, and that we are required t retain ur recrds f the care that we prvided t yu. Ntice f Privacy Practices #3 revised december 9 2013 Page 5 f 8 Last printed 0/0/0000

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU Althugh yur health recrd is the prperty f Centre Crest, the infrmatin belngs t yu. Yu have the fllwing rights regarding yur medical infrmatin: Right t Inspect and Cpy. With sme exceptins, yu have the right t review and cpy yur medical infrmatin. Yu must submit yur request in writing t Health Infrmatin Management. We may charge a fee fr the csts f cpying, mailing r ther supplies assciated with yur request. Right t Amend. If yu feel that medical infrmatin in yur recrd is incrrect r incmplete, yu may ask us t amend the infrmatin. Yu have this right fr as lng as the infrmatin is kept by r fr Centre Crest facility. Yu must submit yur request in writing t the Administratr. In additin, yu must prvide a reasn fr yur request. We may deny yur request fr an amendment if it is nt in writing r des nt include a reasn t supprt the request. In additin, we may deny yur request if yu ask us t amend infrmatin that: Was nt created by us, unless the persn r entity that created the infrmatin is n lnger available t make the amendment; Is nt part f the medical infrmatin kept by r fr Centre Crest; r Is accurate and cmplete. Right t an Accunting f Disclsures. Yu have the right t request an "accunting f disclsures". This is a list f certain disclsures we made f yur medical infrmatin, ther than thse made fr purpses such as treatment, payment, r health care peratins. Yu must submit yur request in writing t the Administratr. Yur request must state a time perid, which may nt be lnger than six (6) years frm the date f the request is submitted and may nt include dates befre April 14, 2003. Yur request shuld indicate in what frm yu want the list (fr example, n paper r electrnically). The first list yu request within a 12 mnth perid will be free. Fr additinal lists, we may charge yu fr the csts f prviding the list. We will ntify yu f the cst invlved and yu may chse t withdraw r mdify yur request at that time befre any csts are incurred. Right t Request Restrictins. Yu have the right t request a restrictin r limitatin n the medical infrmatin we use r disclse abut yu. Fr example, yu may request that we limit the medical infrmatin we disclse t smene wh is invlved in yur care r the payment fr yur care. Yu culd ask that we nt use r disclse infrmatin abut a surgery yu had t a family member r friend. We typically are nt required t agree t yur request. Hwever, we must cmply with yur request if yu request that we d nt disclse infrmatin t a health plan r ther third party payer abut services which yu r sme ther persn (ther than the third party payer) has paid fr in full, unless a law requires us t share the infrmatin. If we d agree, we will cmply with yur request unless the infrmatin is needed t prvide yu emergency treatment. Ntice f Privacy Practices #3 revised december 9 2013 Page 6 f 8 Last printed 0/0/0000

Yu must submit yur request in writing t the Administratr. In yur request, yu must tell us (1) what infrmatin yu want t limit; (2) whether yu want t limit ur use, disclsure r bth; and (3) t whm yu want the limits t apply, fr example, disclsures t yur spuse. Right t Request Alternate and Cnfidential Cmmunicatins. Yu have the right t request that we cmmunicate with yu abut medical matters in a cnfidential manner r at a specific lcatin. Fr example, yu may ask that we nly cntact yu via mail t a pst ffice bx. Yu must submit yur request in writing t the Administratr. We will nt ask yu the reasn fr yur request. Yur request must specify hw r where yu wish t be cntacted. We will accmmdate all reasnable requests. Right t a Paper Cpy f This Ntice. Yu have the right t a paper cpy f this ntice even if yu have agreed t receive the ntice electrnically. Yu may ask us t give yu a cpy f this ntice at any time. Yu may btain a cpy f this ntice at ur website, www.centrecrest.rg. T btain a paper cpy f this ntice, cntact 814 355 6777. CHANGES TO THIS NOTICE We reserve the right t change this ntice. We reserve the right t make the revised r changed ntice effective fr medical infrmatin we already have abut yu as well as any infrmatin we receive in the future. We will pst a cpy f the current ntice in the Centre Crest facility r n the website (www.centrecrest.rg). The ntice will specify the effective date n the first page, in the tp left hand crner. In additin, if material changes are made t this ntice, the ntice will cntain an effective date fr the revisins and cpies can be btained by cntacting Centre Crest facility administratr. COMPLAINTS If yu believe yur privacy rights have been vilated, yu may file a cmplaint with the Centre Crest facility r with the Secretary f the Department f Health and Human Services. T file a cmplaint with Centre Crest, cntact the Administratr at 814 355 6777. All cmplaints must be submitted in writing. Yu will nt be penalized fr filing a cmplaint. ACKNOWLEDGEMENT I acknwledge receipt f the Facility Ntice f Privacy Practices prvided in accrdance with the HIPAA Privacy Standards. Resident/Respnsible Party Ntice f Privacy Practices #3 revised december 9 2013 Page 7 f 8 Last printed 0/0/0000

Date Reference: 164.520 Disclaimer: This plicy and prcedure has been prvided by cnsultants f Cmplete HealthCare Resurces, Inc. fr the use f engaged facilities. This dcument is nt t be cnsidered as facility specific plicy, but is meant fr the purpses f example t establishing facility plicy. Ntice f Privacy Practices #3 revised december 9 2013 Page 8 f 8 Last printed 0/0/0000