CLASSIC RESIDENCE BY HYATT
PALO ALTO
NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. INTRODUCTION

   During the course of providing services and care to you, Classic Residence by Hyatt gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is characterized as your "protected health information." This Notice of Privacy Practices describes how Classic Residence by Hyatt maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.

2. CLASSIC RESIDENCE BY HYATT'S RESPONSIBILITIES

   Classic Residence by Hyatt is required by federal and state law to maintain the privacy of your protected health information. Classic Residence by Hyatt is also required by law to provide you with this Notice of Privacy Practices that describes Classic Residence by Hyatt's legal duties and privacy practices with respect to your protected health information. Classic Residence by Hyatt will abide by the terms of this Notice of Privacy Practices. Classic Residence by Hyatt reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that it maintains, including protected health information already in its possession. If Classic Residence by Hyatt changes its Notice of Privacy Practices, it will personally deliver or mail a revised notice to you at your current address.

3. USE AND DISCLOSURE WITH YOUR AUTHORIZATION

   Classic Residence by Hyatt will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. Classic Residence by Hyatt has prepared an authorization form for you to use that authorizes Classic Residence by Hyatt to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. Classic Residence by Hyatt then will not use or disclose your protected health information, except where it has already relied on your authorization.

4. HOW CLASSIC RESIDENCE BY HYATT MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION
   1. Permissive Disclosures

      Classic Residence by Hyatt may, in its discretion, use or disclose your protected health information without your written authorization in the following circumstances:

      1. Your Care and Treatment

         Classic Residence by Hyatt may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For example, Classic Residence by Hyatt may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. Classic Residence by Hyatt may also disclose your protected health information to individuals who will be involved in your care if you leave Classic Residence by Hyatt in Palo Alto.

      2. Billing and Payment

         i. Medicare, Medi-Cal and Other Public or Private Health Insurers - Classic Residence by Hyatt may use or disclose your protected health information to public or private health insurers (including medical insurance carriers, HMOs, Medicare, and Medi-Cal) in order to bill and receive payment for your treatment and services that you receive at Classic Residence by Hyatt in Palo Alto. The information on or accompanying a bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

         ii. Health Care Providers - Classic Residence by Hyatt may also disclose your protected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed.

      3. Health Care Operations

         Classic Residence by Hyatt may use your protected health information for its health care operations at Classic Residence by Hyatt in Palo Alto. These uses and disclosures are necessary to manage Classic Residence by Hyatt in Palo Alto and to monitor our quality of services and care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff caring for you.

      4. Licensing and Accreditation

         Classic Residence by Hyatt may disclose your protected health information to any government or private agency, such as to the California Department of Health Services and the California Department of Social Services, responsible for licensing or accrediting Classic Residence by Hyatt in Palo Alto so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.

      5. Provision of Basic Information about Residents

         Classic Residence by Hyatt allows staff to provide certain basic information about a resident to persons who ask for the resident by name and to members of the clergy. Unless you notify Classic Residence by Hyatt that you object, it will disclose your name, your location at Classic Residence by Hyatt in Palo Alto, and your general condition to anyone who asks for you by name. It will disclose your name, your location Classic Residence by Hyatt in Palo Alto, your general condition, and your religious affiliation to members of the clergy.

      6. Individuals Involved in Your Care or Payment for Your Care

         Unless you specifically object, Classic Residence by Hyatt may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person's involvement with your care or directly relevant to payment related to your care. Classic Residence by Hyatt may also disclose your protected health information to a family member, personal representative, or other person responsible for your care to assist in notifying them of your location, general condition, or death.

      7. Disaster Relief

         Classic Residence by Hyatt may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.

      8. Disclosures within the Provider Community

         Unless you specifically object, Classic Residence by Hyatt may disclose certain general information about you (e.g., past activities, present interests, birthday, and location if hospitalized) to members of its community, including other residents and staff, by means such as newsletter or bulletin board.

      9. Business Associates

         Classic Residence by Hyatt may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, quality assurance, legal, or accounting services. Classic Residence by Hyatt may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on Classic Residence by Hyatt's behalf. Classic Residence by Hyatt will have a contract with its business associates that obligate the business associates to maintain the confidentiality of your protected health information.

      10. Hospital Peer Review

          Classic Residence by Hyatt may disclose your protected health information to hospital medical staffs to aid in the credentialing of applicants and in the peer review of members.

      11. Organ Procurement

          Classic Residence by Hyatt may disclose your protected health information following your death to an organ procurement agency or tissue bank in order to aid in using your organs or tissues in transplantation.

      12. Medical Examiner or Funeral Director

          Classic Residence by Hyatt may disclose protected health information to a medical examiner or funeral director to allow them to carry out their duties.

      13. Treatment Alternatives or Health-Related Benefits and Services

          Classic Residence by Hyatt may use or disclose your protected health information to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.

      14. Members of Workforce

          It is Classic Residence by Hyatt's policy to allow members of its workforce to share residents' protected health information with one another to the extent necessary to permit them to perform their legitimate functions on Classic Residence by Hyatt's behalf. At the same time, Classic Residence by Hyatt will work with and train its workforce members to ensure that there are no unnecessary or extraneous communications that will violate the rights of its residents to have the confidentiality of their protected health information maintained.

      15. Veterans

          Classic Residence by Hyatt may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits

      16. Workers' Compensation

          Classic Residence by Hyatt may use or disclose your protected health information to comply with laws relating to workers' compensation or similar programs.

   2. Mandatory Disclosures

      Classic Residence by Hyatt will disclose protected health information to outside persons or entities without your written authorization as required by law in the following circumstances:

      1. Court Order; Order of Administrative Tribunal

         Classic Residence by Hyatt will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency.

      2. Subpoena

         Classic Residence by Hyatt will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.

      3. Law Enforcement Agencies

         Classic Residence by Hyatt will disclose protected health information to law enforcement agencies in accordance with a search warrant, a grand jury subpoena, a court order or court-ordered subpoena, or an investigative subpoena or summons.

      4. Coroner

         Classic Residence by Hyatt will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to notify next of kin; or to investigate deaths that may involve public health concerns, suspicious circumstances, elder abuse, or organ or tissue donation.

      5. Elder Abuse Reporting

         Classic Residence by Hyatt will disclose protected health information about a resident who is suspected to be the victim of elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain circumstances, Classic Residence by Hyatt may disclose further protected health information about the resident to aid the investigating agency in performing its duties. Classic Residence by Hyatt will promptly inform the resident about any disclosure unless Classic Residence by Hyatt believes that informing the resident would place the resident in danger of serious harm, or would be informing the resident's personal representative, whom Classic Residence by Hyatt believes to be responsible for the abuse, and believes that informing such person would not be in the resident's best interest.

      6. National Security and Intelligence Activities, Protected Services for the President and Others

         Classic Residence by Hyatt will disclose protected health information about a resident to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states, or to conduct certain special investigations.

      7. Other Disclosures Required by Law

         Classic Residence by Hyatt will disclose protected health information about a resident when otherwise required by law.

5. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION

   You have the following rights with respect to your protected health information. To exercise these rights, contact Classic Residence by Hyatt at the following address:Classic Residence by Hyatt in Palo Alto, 620 Sand Hill Road, Palo Alto, California 94304, Attention: Privacy Official.

   1. Right to Request Access

      You have the right to inspect and copy your protected health information maintained by Classic Residence by Hyatt. In certain limited circumstances, Classic Residence by Hyatt may deny your request as permitted by law. However, you may be given an opportunity to have such denial reviewed by an independent licensed health care professional.

   2. Right to Request Amendment

      You have the right to request an amendment to your protected health information maintained by Classic Residence by Hyatt. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an opportunity to submit a written statement disagreeing with the denial.

   3. Right to Request Restriction

      You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. Classic Residence by Hyatt is not required to grant your request, but if it does, it will comply with your request, except in an emergency situation or until the restriction is terminated by you or Classic Residence by Hyatt.

   4. Right to Request Confidential Communications

      You have the right to request that Classic Residence by Hyatt communicate protected health information to the recipient by alternative means or at alternative locations.

   5. Right to an Accounting

      You have the right to receive an accounting of disclosures of your protected health information created and maintained by Classic Residence by Hyatt over the six years prior to the date of your request or for a lesser period. Classic Residence by Hyatt is not required to provide an accounting of the following disclosures:

      • To carry out treatment, payment, and health care operations;
      • To respond to your requests for access to protected health information;
      • To release basic information about you to persons asking for you by name or to members of the clergy;
      • To aid in the identification or care of a resident;
      • To any recipient, where such disclosure was incident to a use or disclosure otherwise permitted or required by law;
      • To any recipient pursuant to a written authorization from the resident or the resident's personal representative;
      • To any recipient for national security or intelligence purposes as required by law; or
      • To any recipient prior to April 14, 2003 or for protected health information created more than six years before the date of your request for an accounting.
   6. Right to Receive a Copy of the Notice of Privacy Practices

      You have the right to request and receive a copy of Classic Residence by Hyatt's Notice of Privacy Practices for Protected Health Information in written or electronic form.

6. COMPLAINTS

   If you believe that your privacy rights have been violated, you may file a complaint with Classic Residence by Hyatt at the following address: Classic Residence by Hyatt in Palo Alto, 620 Sand Hill Road, Palo Alto, California 94304, Attention: Privacy Official. You also have the right to submit a complaint to the Secretary of the U.S. Department of Health and Human Services, 50 United Nations Plaza Room 322, San Francisco, CA 94102, Attention OCR Regional Manager. Classic Residence by Hyatt will not retaliate against you if you file a complaint.

7. FURTHER INFORMATION

   If you have questions about this Notice of Privacy Practices or would like further information about your privacy rights, contact Classic Residence by Hyatt at the following address: Classic Residence by Hyatt in Palo Alto, 620 Sand Hill Road, Palo Alto, California 92122, Attention: Privacy Official.

The effective date of this Notice of Privacy Practices is April 14, 2003