Last edit made Apr 16, 2015, and is still in force today.





If you have any questions about this notice,

please contact our privacy officer:

Brenton Tolles

Island Terrace Nursing Home

57 Long Point Rd.

Lakeville, MA 01237


1. Summary of Rights and Obligations Concerning Health Information

Island Terrace, Inc. is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Island Terrace, Inc.

Each time you visit a hospital, physician, or other healthcare provider a record of your visit is made.

Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. Each time we provide nursing facility services to you, we make a record of the services provided.

We have a legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information to:

plan your care and treatment;

provide treatment by us or others;

communicate with other providers such as referring hospitals;

receive payment from you, Medicare, Medicaid, your health plan, or your health insurer;

make quality assessments and work to improve the care we render and the outcomes we achieve, known as health care operations;

make you aware of services and treatments that may be of interest to you;

and comply with state and federal laws that require us to disclose your health information.

We may also use or disclose your health information where you have authorized us to do so.

You have certain rights to your health information. You have the right to:

ensure the accuracy of your health record;

request confidential communications between you and your healthcare provider;

request limits on the use and disclosure of your health information;

and request an accounting of certain uses and disclosures of health information we have made about you.

We are required to:

maintain the privacy of your health information;

provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy practices with respect to health information we collect and maintain about you;

abide by the terms of our most current Notice of Privacy Practices;

notify you if we are unable to agree to a requested restriction;

and accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain.

Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law.

We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.

In the following sections, we explain our privacy practices and your rights to your health information in more detail.


2. We May Use or Disclose Your Health Information In The Following Ways

A. Treatment. We may use your health information to provide you with medical treatment or services. For example, health information obtained by a nurse, physician, or other member of your healthcare team may be recorded in your record and used to determine the best course of treatment for you. By recording your current health care information, in the future, we can see your medical history to help in diagnosing and treatment, or to determine how well you are responding to treatment. We may provide your health information to other health providers, such as specialist physicians, to assist in your treatment. Should you ever be hospitalized, we may provide the hospital or its staff with the health information it requires to provide you with effective treatment.

B. Payment. We may use and disclose your health information so that we may bill and collect payment for the services that you may receive from us. For example, we may contact your health insurer to verify your eligibility for benefits, and may need to disclose to it some details of your medical condition or expected course of treatment. We may use or disclose your information so that a bill may be sent to you, your health insurer, or a family member. The information on or accompanying the bill may include information that identifies you and your diagnosis, as well as services rendered, any procedures performed, and supplies used. Also, we may provide health information to another health care provider, such as an ambulance company that transported you to a hospital, to assist in the health care provider's billing and collection efforts.

C. Health care operations. We may use and disclose your health information to assist in the operation of our facility. For example, facility staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the nursing facility care and services we provide. We may use and disclose your health information to conduct cost-management and business planning activities for our facility. We may also provide such information to other health care entities for their health care operations. For example, we may provide information to your health insurer for its quality review purposes.

D. MDS Transmission. Nursing facilities participating in Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident’s functional capacity and health status. This information is used to aid in the administration of the survey and certification of Medicare/Medicaid nursing facilities and to improve the effectiveness and quality of care given in those facilities. The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing facilities and is also necessary for the nursing facilities to receive reimbursement for Medicare/Medicaid services.

E. Nursing Students and other Interns. Nursing students and other interns, ie Social worker, may observe or participate in your treatment or use your health information to assist in their training. You have the right to refuse to be examined, observed, or treated by nursing students or other interns.

F. Business Associates. Island Terrace, Inc. sometimes contracts with third-party business associates for services. Examples include companies providing laboratory tests, billing services, consultants, and legal counsel. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information.

G. Directory. Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people that ask for you by name.

H. Treatment Options. We may use and disclose your health information in order to inform you of alternative treatments.

I. Photographs and Memory Boards. Photographs or videotapes may be taken of you as a means of identification in case of emergency or for health-related purposes. If you provide us with an authorization, photographs or videotapes also may be taken for holiday activities, memory boards, cue boxes and resident of the month announcements. In addition, if you provide us with an authorization, we may display within the facility a written summary about your life history, hobbies, and/or personal information to provide resident cueing and enhance quality of life.

J. Release to Family/Friends. Our health care professionals, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so If you are not present or able to agree or object to the use or disclosure we will use our professional judgment to determine whether the disclosure is in your best interest.

K. Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. In face- to-face communications we may tell you about other products and services that may be of interest you.

L. Newsletters and Other Communications. We may use your personal information in order to communicate to you via newsletters, mailings, or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community-based initiatives or activities in which our facility is participating.

M. Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief organizations seek your health information to coordinate your care, or notify family and friends of your location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.

N. Marketing. In most circumstances, we are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may provide you with promotional gifts of nominal value. Under no circumstances will we sell our resident lists or your health information to a third party without your written authorization.

O. Fundraising. We may contact you as part of a fundraising effort relating to the facility.


P. Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following:

licensing and certification carried out by public health authorities;

prevention or control of disease, injury, or disability;

reports of births and deaths;

reports of child abuse or neglect;

notifications to people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

organ or tissue donation; and notifications to appropriate government authorities if we believe a resident has been the victim of abuse, neglect, or domestic violence. We will make this disclosure when required by law, or if you agree to the disclosure, or when authorized by law and in our professional judgment disclosure is required to prevent serious harm.

Q. Funeral Directors. We may disclose health information to funeral directors so that they may carry out their duties.

R. Food and Drug Administration (FDA). We may disclose to the FDA and other regulatory agencies of the federal and state government health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing monitoring information to enable product recalls, repairs, or replacement.

S. Psychotherapy Notes. Under most circumstances, without your written authorization we may not disclose the notes a mental health professional took during a counseling session.  However, we may disclose such notes for treatment and payment purposes, for state and federal oversight of the mental health professional, for the purposes of medical examiners and coroners, to avert a serious threat to health or safety, or as otherwise authorized by law.

T. Research. We may disclose your health information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.

U. Workers Compensation. We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

V. Law Enforcement. We may release your health information:

in response to a court order, subpoena, warrant, summons, or similar process if authorized under state or federal law;

to identify or locate a suspect, fugitive, material witness, or similar person;

about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

about a death we believe may be the result of criminal conduct;

about criminal conduct at Island Terrace, Inc. to coroners or medical examiners;

in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime;

to authorized federal officials for intelligence, counterintelligence, and other national security authorized by law; and to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons, or foreign heads of state.

W. De-identified Information. We may use your health information to create "de-identified" information or we may disclose your information to a business associate so that the business associate can create de-identified information on our behalf. When we "de-identify" health information, we remove information that identifies you as the source of the information.

Health information is considered "de-identified" only if there is no reasonable basis to believe that the health information could be used to identify you.

X. Personal Representative. If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information.

If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative.

Y. Limited Data Set. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health, and health care operations. We may not disseminate the limited data set unless we enter into a data use agreement with the recipient in which the recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security of the data, and not identify the information or use it to contact any individual.

3. Authorization for Other Uses of Health Information

Uses of health information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization.

If you provide us with authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.

4. Your Health Information Rights

You have the following rights regarding health information we gather about you:

A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.

B. Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. To inspect and copy health information, you must submit a request to Brenton Tolles [privacy officer]. We will supply you with a form for such a request. If you request a copy of your health information, Island Terrace, Inc. may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your health information for a claim for benefits under the Social Security Act (such as claims for Social Security, Supplemental Security Income, and MassHealth benefits) or any other state or federal needs-based benefit program.

C. Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we retain the information.

To request an amendment, your request must be made in writing and submitted to Brenton Tolles (privacy officer). In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

was not created by Island Terrace, Inc. unless the person or entity that created the information is no longer available to make the amendment;

is not part of the health information kept by or for Island Terrace, Inc.;

is not part of the information which you would be permitted to inspect and copy;

or is accurate and complete.

If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement.

D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your health information made by Island Terrace, Inc.

In your accounting, we are not required to list certain disclosures, including:

disclosures made for treatment, payment, and health care operations purposes or disclosures

made incidental to treatment, payment, and health care operations;

disclosures made pursuant to your authorization;

disclosures made to create a limited data set;

disclosures made directly to you or your personal representative;

disclosures made to correctional institutions or law enforcement officials having lawful custody of you;

disclosures made for national security or intelligence purposes;

disclosures made for notification purposes such as in an emergency;

disclosures made for our facility directory.

To request an accounting of disclosures, you must submit your request in writing to Brenton Tolles [privacy officer]. Your request must state a time period which may not be longer than six years (from current date) and may not include dates before April 14, 2003. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.

E. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations.

You also have the right to request a limit on the health information we communicate about you to someone who is involved in your care or the payment for your care.

We are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment.

To request restrictions, you must make your request in writing to Brenton Tolles [privacy officer]. In your request, you must tell us:

what information you want to limit;

whether you want to limit our use, disclosure, or both;

and to whom you want the limits to apply.

F. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact your personal representative at home or by e-mail.

To request confidential communications, you must make your request in writing to Brenton Tolles [privacy officer]. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

5. Complaints

If you believe your privacy rights have been violated, you may file a complaint with Island Terrace, Inc. You may also file a complaint with the Regional Office for Civil Right (OCR). We will provide you with the address upon request. To file a complaint with us, contact Brenton Tolles [privacy officer] at the address listed at the top and the bottom of this document. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred.  You will not be penalized for filing a complaint.

For more information, visit the

Office for Civil Rights website


Brenton Tolles

Island Terrace Nursing Home

PO Box 1237, 57 Long Point Rd, Lakeville, MA 02347

Voice (508) 947-0151 Fax (508) 946-5335