Privacy Policy



This Facility is required by law to provide you with this Notice so that you will understand how we may use or share your information from your Designated Record Set.  The Designated Record Set includes financial and health information as “Protected Health Information” (“PHI”) or simply “health information.”  We are required to adhere to the terms outlined in this Notice.  If you have any questions about this Notice, please contact Social Services or the Administrator.


  • This notice describes our practices and that of:
  • Any health care professional authorized to enter information into your health record.
  • All divisions and programs of the Suncrest Health Care Communities and Adult Care Center.
  • Any volunteer we allow to help you while you are receiving services from Suncrest Health Care Communities and Adult Care Center.
  • All employees, staff and other personnel.
  • All Suncrest Health Care Communities and Adult Care Centers entities, sites and locations follow the terms of this notice.  Staff members at these entities, sites and locations may share health information with each other for treatment, payment or operations purposes as described in this notice.


We understand that health information about you and your health is personal.  We are committed to protecting your privacy and health information about you.  We create a record of the care and services you receive at Suncrest Health Care Communities and Adult Care Center.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by Suncrest Health Care Communities and Adult Care Center personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose health information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:

  • Make sure that health information that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices with respect to health information about you; and
  • Follow the terms of the notice that is currently in effect.


Each time you are admitted to our Facility, a record of your stay is made containing health and financial information.  Typically, this record contains information about your condition, the treatment we provide and payment for the treatment.  We may use and/or disclose this information to:

  • plan your care and treatment
  • communicate with other health professionals involved in your care
  • document the care you receive
  • educate health professionals
  • provide information for medical research
  • provide information to public health officials
  • evaluate and improve the care we provide
  • obtain payment for the care we provide

Understanding what is in your record and how your health information is used helps you to:

  • ensure it is accurate
  • better understand who may access your health information
  • make more informed decisions when authorizing disclosure to others


The Facility uses an electronic health record to store and retrieve much of your health information.  One of the advantages of the Facility’s electronic health record is the ability to share and exchange health information among Facility personnel and other community health care providers who are involved in your care.  When the Facility enters your information into the electronic health record, it may share that information as permitted by law by using shared clinical databases or health information exchanges.  The Facility may also receive information about you from other health care providers in the community who are involved with your care by using shared databases or health information exchanges.  We may also seek your consent to access medical information from your other health care providers that is available on the Vermont Health Information Exchange (“VHIE”).  For information about the VHIE, see  If you have questions or concerns about the sharing or exchange of your information, please discuss them with your provider.


The following categories describe the ways that we use and disclose health information.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall into one of the categories.

For Treatment.  We may use or disclose health information about you to provide you with medical treatment.  We may disclose health information about you to doctors, nurses, therapists or other Facility personnel who are involved in taking care of you at a Facility.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian if you have diabetes so that we can plan your meals.  Different departments of a Facility also may share health information about you in order to coordinate your care and provide you medication, lab work, and x-rays.  We may also disclose health information about you to people outside the facility who may be involved in your medical care after you leave a Facility.  This may include family members, or visiting nurses to provide care in your home.

For Payment.  We may use and disclose health information about you so that the treatment and services you receive at a Facility may be billed to you, an insurance company or a third party.  For example, in order to be paid, we may need to share information with your health plan about services provided to you.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.  Your health plan may request additional information.

For Health Care Operations.  We may use and disclose health information about you for our day-to-day health care operations.  This is necessary to ensure that all residents receive quality care.  For example, we may use health information for quality assessment and improvement activities and for developing and evaluating clinical protocols.  We may also combine health information about many residents to help determine what additional services should be offered, what services should be discontinued, and whether certain new treatments are effective.  Health information about you may be used by our corporate office for business development and planning, cost management analyses, insurance claims management, risk management activities, and in developing and testing information systems and programs.  We may also use and disclose information for professional review, performance evaluation, and for training programs.  Other aspects of health care operations that may require use and disclosure of your health information include accreditation, certification, licensing and credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.  Your health information may be used and disclosed for the business management and general activities of the Facility including resolution of internal grievance, customer service and due diligence in connection with a sale or transfer of the Facility.  In limited circumstances, we may disclose your health information to another entity subject to HIPAA for its own health care operations.  We may remove information that identifies you so that the health information may be used to study health care and health care delivery without learning the identities of residents.  We may disclose your age, birth date and general information about you in the Facility newsletter, on activities calendars, and to entities in the community that wish to acknowledge  your birthday or commemorate your achievements on special occasions.  If you are receiving therapy services, we may post your photograph and general information about your progress.

Fundraising Activities.  Should the need arise where information about you or where your participation is desired for fundraising activities, Suncrest Health Care Communities and Adult Care Center would obtain your authorization.  No information would be released for this purpose without your authorization.  For example, if the Facility was creating a fund-raising brochure and picture of or comments from persons served were desired, the Facility would inquire whether or not you would be willing to participate.  Participation would be voluntary and if you agreed, you would be asked to give us written permission for the specific purpose.

Marketing.  Health information about you cannot be used for marketing purposes without your authorization, unless the activity relates to certain permitted exceptions that relate to your treatment or care.

Facility Directory.  Unless you object, we may include certain limited information about you in the Facility’s directory while you are a resident, so your family, friends and clergy can visit you and generally know how you are doing.  This information may include your name, location in the Facility, your general condition and your religious affiliation.  The directory information, except for your religious affiliation may be given to people who ask for you by name.  Your name and religious affiliation may be given to a member of the clergy even if they do not ask for you by name.

Individuals Involved in Your Care or Payment for Your Care.  Unless you object, we may release relevant health information about you to a friend or family member who is involved in your medical care or who helps pay for your care.


Business Associates.  There are some services provided in our Facility through contracts with business associates.  Examples include medical directors, outside attorneys and a copy service we use when making copies of your health record.  When these services are contracted, we may disclose your health information so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered.  To protect your health information, however, we require the business associate to appropriately safeguard your information.

Providers.  Many services provided to you, as part of your care at our Facility, are offered by participants in one of our organized healthcare arrangements.  These participants include a variety of providers such as physicians (e.g., MD, DO, Podiatrist, Dentist, Optometrist), therapists (e.g., Physical therapist, Occupational therapist, Speech therapist), portable radiology units, clinical labs, hospice caregivers, pharmacies, psychologists, LCSWs, and suppliers (e.g., prosthetic, orthotics).

Treatment Alternatives.  We may use and disclose health information to tell you about possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services and Reminders.  We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

As Required By Law.  We will disclose health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety.  We may use and disclose health information about you to prevent a serious threat to your health and safety or the health and safety of the public or another person.  We would do this only to help prevent the threat.

Organ and Tissue Donation.  If you are an organ donor, we may disclose health information to organizations that handle organ procurement to facilitate donation and transplantation.

Military and Veterans.  If you are a member of the armed forces, we may disclose health information about you as required by military authorities.  We may also disclose health information about foreign military personnel to the appropriate foreign military authority.

Research.  Under certain circumstances, we may use and disclose health information about you for research purposes.  For example, a research project may involve comparing the health and recovery of all residents who receive one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of health information, trying to balance the research need with residents’ need for privacy of their health information.  Before we use or disclose health information for research, the project will have been approved through this research approval process.  We may, however, disclose health information about you to people preparing to conduct a research project so long as the health information they review does not leave the Facility.

Workers’ Compensation.  We may disclose health information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Reporting.  Federal and state laws may require or permit the Facility to disclose certain health information related to the following:

  • Public Health Risks.  We may disclose health information about you for public health purposes, including:
    • Prevention or control of disease, injury or disability
    • Reporting deaths;
    • Reporting reactions to medications or problems with products;
    • Notifying people of recalls of products;
    • Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;

Health Oversight Activities.  We may disclose health information to a health oversight agency for activities authorized by law.  These oversight activities may include audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings:  If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order.

Reporting Abuse, Neglect or Domestic Violence:  Notifying the appropriate government agency if we believe a resident has been the victim of abuse, neglect or exploitation.

Law Enforcement.  We may disclose health information when requested by a law enforcement official:

  • In response to a court order or warrant;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the Facility; and
  • 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.

Coroners, Medical Examiners and Funeral Directors.  We may disclose medical information to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death.  We may also disclose medical information to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities.  We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Correctional Institution.  Should you be an inmate of a correctional institution, we may disclose to the institution or its agents health information necessary for your health and the health and safety of others.


We may make other uses and disclosures of your health information only with your specific written authorization.  Specifically, we may not use or disclose your health information for marketing purposes and we may not sell your health information without your written authorization.  Additionally, if psychotherapy notes are part of your health information, they may not be disclosed unless you provide written authorization.

If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided you.


Although your health record is the property of the Facility, the information belongs to you.  You have the following rights regarding your health information:

Right to Inspect and Copy.  With some exceptions, you have the right to review and copy your health information.

You must submit your request in writing to administration.  We may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.  Usually this includes medical and billing records, but does not include psychotherapy notes, if applicable.  We may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.  If you seek an electronic copy of your electronic medical record in a specific form and format that is not readily producible, we will work with you on providing an alternative.  Under very limited circumstances, we may deny your request to inspect or receive a copy of your health information.  If you are denied access to your health information, you may request in writing the denial be reviewed.  To request a review, contact Coleen Kohaut, NHA, RSD.  A licensed healthcare professional chosen by the facility will conduct the review.  The person conducting the review will not be the person who denied your request.  We will comply with the decision of the reviewer.

Right to Amend.  If you feel that health information in your record is incorrect or incomplete, you may ask us to amend the information.  You have this right for as long as the information is kept by the Facility.

You must submit your request in writing to Coleen Kohaut, NHA, RSD.  In addition, you must provide a reason for 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 us, 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 the Facility; or
  • Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”.  This is a list of certain disclosures we made of your health information, other than those made for purposes such as treatment, payment or health care operations.

You must submit your request in writing to Coleen Kohaut, NHA, RSD.  Your request must state a time period which may not be longer than six years from the date the request is submitted.  Your request should indicate in what form you want the list (for example, on paper or electronically).  The first list you request within a twelve month period will be free.  For additional lists, we may charge you for the costs of providing the list.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

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 example, you may request that we limit the health information that we disclose to someone who is involved in your care or the payment for your care.  You could ask that we not use your disclose information about a surgery you had to a family member or friend.

We are not required to agree to your request, except a request to limit access by, or disclosure to, a health plan if you have paid for the health services at the time of service.  If we do agree to, or are required by law to, restrict, we will comply with your request unless the information is needed to provide you emergency treatment.

You must submit your request in writing to Coleen Kohaut, NHA, RSD.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Alternate Communications.  You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location.  For example, you may ask that we only contact you via mail to a post office box.

You must submit your request in writing to Coleen Kohaut, NHA, RSD.  We will not ask you the reason for your request.  Your request must specify how or where you wish to be contacted.  We will accommodate all reasonable requests.

Right to a Paper Copy of this Notice.  You have the right to a paper copy of this Notice of Privacy Practices even if you have agreed to receive the Notice electronically.  You may ask us to give you a copy of this Notice at any time.

To obtain a paper copy of this Notice, Contact Coleen Kohaut, NHA, RSD.

Right to Receive Notification Following a Breach of your Health Information.  We will provide you written notification in the event of a breach of the confidentiality of your health information.


We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future.  We will post a copy of the current Notice in the facility and on the website.  The Notice will specify the effective date on the first page, in the top right- hand corner.  In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Facility administrator.


If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of the Department of Health and Human Services.  To file a complaint with the Facility, contact Coleen Kohaut, NHA, RSD.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

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