UNIVERSITY VILLAGE THOUSAND OAKS
NOTICE OF PRIVACY PRACTICES
March 30, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your privacy is a high priority for us and it will be treated with the highest degree of confidentiality. This Notice applies to all information and records related to your care that we have received or created. It extends to information received or created by our employees, staff, volunteers, physicians and medical personnel (e.g. therapists). This Notice informs you about the possible uses and disclosures of your protected health information. It also describes your rights and obligations regarding your protected health information.

In order for us to be able to provide you with the best service and care, we need to receive protected health information from you. However, we want to emphasize that we are committed to maintaining the privacy of this information in accordance with state and federal laws.

We are required by law to

• Maintain the privacy of your protected health information;
• Provide to you this detailed Notice of our legal duties and privacy practices relating to your protected health information; and
• Abide by the terms of the Notice that is currently in effect. We reserve the right to change the terms of this Notice and make the new Notice provisions effective for all protected health information that University Village Thousand Oaks maintains.

PROTECTED HEALTH INFORMATION

While receiving care from University Village Thousand Oaks, information regarding your medical history, treatment, and payment for your health care may be originated and/or received by us. Information which can be used to identify you and which relates to your medical care or your payment for medical care is protected by state and federal law. This is your protected health information.

COLLECTING INFORMATION

We collect protected information about you to help us provide the best service, assistance and care, provide billing services and to fulfill legal and regulatory requirements. The type of information University Village Thousand Oaks may receive from you varies according to the assistance and care that you may need.

If we become aware that an item of your protected health information may be materially inaccurate, we will make a reasonable effort to re-verify its accuracy and correct any error as appropriate.

In accordance with our Privacy Policies, by providing your name, telephone number and checking the box on our Request Information form, you acknowledge you have read and understand our Privacy Policies. You also grant permission for representatives of University Village Thousand Oaks to communicate with you at this phone number. Your personal information is confidential and will not be released or sold to outside parties.

SECURITY STANDARDS

We continue to assess new technology to evaluate its ability to provide additional protection of your protected health information. We maintain physical, electronic and procedural safeguards that comply with state and federal standards to guard your protected health information.

USING AND DISCLOSING YOUR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

You will be asked to sign an acknowledgment of receipt of this notice, allowing us to use and disclose your protected health information for purposes of treatment, payment and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories.

For Treatment. We will use and disclose your protected health information in providing you with treatment and services. We may disclose your protected health information to community and non-community personnel who also may be involved in your care, including, but not limited to, physicians, nurses, nurse aides, and physical therapists. Employees' access to such information is on a need to know basis. For example, a nurse caring for you will report any change in your condition to your physician. Your physician may need to know the medications you are taking before prescribing additional medications. It may be necessary for the physician to inform the nurses or staff of the medications you are taking so they can administer the medications and monitor any possible side effects. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services which may be of interest to you.

We also may disclose protected health information to individuals who will be involved in your care outside University Village Thousand Oaks. Employees who have access to protected health information are required to protect it and keep it confidential.

For Payment. We may use and disclose your protected health information so that we can bill and receive payment for the treatment and services you receive at University Village Thousand Oaks. Bills requesting payment will usually include information which identifies you, your diagnosis and any procedures performed or supplies used. For billing and payment purposes, we may disclose your protected health information to your legal representative, an insurance or managed care company, Medicare or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.

For Health Care Operations. We may use and disclose your protected health information for Community operations. These uses and disclosures are necessary to monitor the health status of residents, and monitor the quality of our care. For example, we may use protected health information to evaluate our services, including the performance of our staff. In addition, we may release your Protected Health Information to another individual or covered entity covered by HIPAA regulations for their quality assessment and improvement activities or for review of or evaluation of healthcare professional.

USING AND DISCLOSING PROTECTED HEALTH INFORMATION FOR OTHER SPECIFIC PURPOSES

University Village Thousand Oaks Directory. University Village Thousand Oaks maintains a directory of resident names and their location within University Village Thousand Oaks. Unless you object, we will include certain limited information about you in our University Village Thousand Oaks directory. This information may include (i) your name, (ii) your location in University Village Thousand Oaks, (iii) your general condition and (iv) your religious affiliation. Our directory does not include specific medical information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy. You are not obligated, however, to consent to the inclusion of your information in University Village Thousand Oaks directory. You may restrict or prohibit these uses and disclosures by notifying the Executive Director or Administrator orally or in writing of your restriction or prohibition

In the event of an emergency or your incapacity, we will do what is consistent with your known preference (if any), and what we determine to be in your best interest. We will inform you of any such uses or disclosures under such circumstances and give you an opportunity to object as soon as practicable.

University Village's Community Culture. The culture of our Community includes informing residents and staff of changes in your health status or transfer to a higher level of care to maintain our sense of "community." You may restrict or prohibit these uses and disclosures by notifying the Executive Director or Administrator in writing.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your protected health information to a family member, close personal friend, your legal representative and any clergy, who are involved in your care. You may restrict or prohibit these uses and disclosures by notifying the Executive Director or Administrator orally or in writing of your restriction or prohibition. In most cases, Protected Health Information disclosed for notification purposes will be limited to your name, location and general condition.

Emergencies. In the event of an emergency or your incapacity, we will do what is consistent with your known preference (if any), and what we determine to be in your best interest. We will inform you of any such uses or disclosures under such circumstances and give you an opportunity to object as soon as practicable.

Disaster Relief. We may disclose your protected health information to an organization assisting in a disaster relief effort.

As Required By Law. We will disclose your protected health information when required by law to do so.

Public Health Activities. We may disclose your protected health information for public health activities. These activities may include, for example

• reporting for preventing or controlling disease, injury or disability;
• reporting deaths;
• reporting abuse or neglect;
• reporting reactions to medications or problems with products;
• notifying a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or
• disclosing for certain purposes involving workplace illness or injuries.

Reporting Victims of Abuse, Neglect or Domestic Violence. We may use or disclose your Protected Health Information to a protective services or social services agency or other similar government authority, if we reasonably believe you have been the victim of abuse, neglect or domestic violence as long as you agree to such disclosure and we feel it is necessary to prevent serious harm to you or other individuals. If you are incapacitated and unable to agree to such a disclosure, we may release your Protected Health Information for this purpose but only if failure to release it would materially and adversely effect a law enforcement activity and the information will not be used, in any way, against you.

Health Oversight Activities. We may disclose your protected health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws. In most cases, the oversight activity will be for the purpose of overseeing the care rendered by University Village Thousand Oaks or University Village Thousand Oaks's compliance with certain laws and regulations. University Village Thousand Oaks does not control or define what information is needed by the health oversight agencies.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or other administrative proceedings, we may release your Protected Health Information in response to a court or administrative order requesting the release. In some instances, we may also release Protected Health Information pursuant to a subpoena or discovery request but only if efforts have been made by the requestor to provide you with notice of the request and you have failed to object or the objection was resolved in favor of disclosure, or in the alternative, the requestor has obtained a protective order protecting the requested information.

Law Enforcement. We may also release your Protected Health Information to law enforcement official for the following purposes:

• Pursuant to a court order, warrant, subpoena/summons or administrative request;
• Identifying or locating a suspect, fugitive, material witness or missing person;
• Regarding a crime victim, but only if the victim consents or the victim is unable to consent due to incapacity and the information is needed to determine if a crime has occurred, non-disclosure would significantly hinder the investigation, and disclosure is in the victim's best interest; or
• Regarding a decedent, to alert law enforcement that the individual's death was caused by suspected criminal conduct.
• For reporting suspected criminal activity.

Coroner, Medical Examiners, Funeral Homes. We may release your personal health information to a coroner, medical examiner and/or funeral director. We may also release information to an organization involved in the donation of organs if you are an organ donor.

YOUR RIGHTS

You have the following rights regarding your protected health information at University Village Thousand Oaks:

• The right to receive notice of our policies and procedures used to protect your protected health information;
• The right to request that certain uses and disclosures of your protected health information be restricted;
• The right to access to your protected health information;
• The right to request that your protected health information be amended;
• The right to obtain an accounting of certain disclosures by us of your protected health information for the past six years after April 13, 2003;
• The right to revoke any prior authorizations for use or disclosure of protected health information, except to the extent that University Village Thousand Oaks has acted on your Authorization; and
• The right to request the method by which your protected health information is communicated.

OUR RIGHTS

We have the right not to agree to your requested restrictions on the use or disclosure of your personal health information. If we do agree to accept your requested restrictions, we will comply with your request except as needed to provide you with emergency treatment.?

We have the right to deny your request to inspect or receive copies of your protected health information in certain circumstances.

We have the right to deny your request for amendment of protected health information if it was not created by us, if it is not part of your personal health information maintained by us, if it is not part of the information to which you have a right of access, or if it is already accurate and complete, as determined by us.

AUTHORIZATION

Other uses and disclosures of your protected health information not allowed by law under this Notice will only be made with your Authorization. You can revoke the Authorization as described in your written Authorization. If you revoke your Authorization, we will no longer use or disclose your protected health information for the purposes covered by the Authorization, except where we have already relied on the Authorization.

COMPLAINTS

If you believe your privacy rights have been violated you may file a complaint with us in writing. In order to be responsive to concerns that you may have, the following procedure has been developed:

• You will first be asked to discuss your concern or complaint with a member of University Village Thousand Oaks's staff who can address the matter or who will proceed in the following manner:
• Appropriate staff will discuss your concern or complaint with the Executive Director/Administrator. If there is no resolution of the matter or if you/your family/your representative do not feel comfortable discussing the matter with the Executive Director/Administrator, then
• At any time, you can contact the office of Civil Rights in the U.S. Department of Health and Human Services.
• You will not be retaliated against for filing a complaint.

CHANGES TO THIS NOTICE

We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all protected health information already received and maintained by University Village Thousand Oaks as well as for all protected health information we receive in the future. We will post a copy of the current Notice in University Village Thousand Oaks. In addition, we will provide a copy of the revised Notice to all Residents via the in-house mailbox system.

ACKNOWLEDGEMENT

If you have any questions about this Notice or would like further information concerning your privacy rights please contact the following:
Ryan Exline
University Village Thousand Oaks
Executive Director
(800) 806-0171
03/2003 HIPAA Privacy Notice