NOTICE OF PRIVACY PRACTICES

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.

We are required by law to protect the privacy of medical information about you and that identifies you.
This medical information may include individually identifiable information about care we provide to you;
payment for services provided to you; your past, present, or future medical condition; and demographic
information. For example, it includes information about your diagnosis, medications, insurance status and
policy number, medical claims history, address, and social security number.
We are also required by law to provide you with this Notice explaining our legal duties and privacy
practices and your rights with respect to medical information. We are legally required to follow the terms
of this Notice. In other words, we are only allowed to use and disclose medical information in the manner
that we have described in this Notice.

We may change the terms of this Notice in the future. We reserve the right to make changes and to make
the new Notice effective for all medical information that we maintain. If we make changes to the Notice, we
will post it on our website and make it available in the main office of each community, center, or building
covered by this Notice. In addition, copies of this Notice are available by contacting the Corporate Privacy
Officer at:
Immanuel
Attn: Corporate Privacy Officer
1044 North 115th Street, Suite 500
Omaha, NE 68154
402-829-5573 or 1-855-829-5573 (toll free)
Email: privacyofficer@immanuelcommunities.org

WHO WILL FOLLOW THIS NOTICE
This is the joint Notice of Privacy Practices ("Notice") describing the privacy practices of all of the following
entities participating in the Immanuel Affiliated Covered Entity:

Trinity Village Assisted Living (a division of Immanuel Retirement Communities d/b/a Immanuel
Communities);
PACE Iowa, d/b/a Immanuel Pathways;
PACE Nebraska, d/b/a Immanuel Pathways;
Immanuel Long-Term Care; and
Immanuel Affordable II, Inc.

References to "we" include all entities covered by this joint Notice.

USE AND DISCLOSURE OF MEDICAL INFORMATION WITHOUT YOUR AUTHORIZATION
This section of our Notice explains in some detail how we may use and disclose medical information about
you without your authorization in order to provide health care, obtain payment for that health care,
operate our business efficiently, and for several other functions described below. These are general
descriptions only. They do not cover every example of disclosure within a category
. For more information
about any of these uses or disclosures, or about any of our privacy policies, procedures, or practices,
contact our Corporate Privacy Officer.

1. Treatment
We may use and disclose medical information about you to provide health care treatment to you. In other
words, we may use and disclose medical information about you to provide, coordinate, or manage your
care and related services. This may include communicating with other health care providers regarding your
treatment and coordinating and managing your health care with others.

2. Payment
We may use and disclose medical information about you to obtain payment for services that you received.
This means that we may use and disclose medical information about you to secure payment for services
provided to you under state and Federal reimbursement programs and from insurers and other agencies.
We also may disclose medical information about you to other health care providers and health plans for
their payment purposes. For example, if your condition requires an ambulance, your information will be
given to the ambulance provider for its billing purposes. If state law requires, we will obtain your
permission prior to disclosing your information to other providers or to health insurance companies for
their payment purposes.

3. Healthcare Operations
We may use and disclose medical information about you in performing a variety of business activities
called "health care operations." These "health care operations" activities allow us to deliver our services,
improve the quality of care we provide and reduce health care costs. For example, we may use or disclose
medical information about you in performing the following activities:

Reviewing and evaluating the skills, qualifications, and performance of health care providers taking
care of you.

Providing training programs for students, trainees, health care providers, or non-health care
professionals to help them practice or improve their skills.

Cooperating with outside organizations that evaluate, certify, or license health care providers, staff,
or facilities in a particular field or specialty.

Reviewing and improving the quality, efficiency, and cost of care that we provide to you and our
other residents/participants.

Improving health care and lowering costs for groups of people who have similar health problems
and helping manage and coordinate the care for these groups of people.

Cooperating with outside organizations that assess the quality of the care others and we provide,
including government agencies and private organizations.

Planning for our organization's future operations.
Resolving grievances within our organization.
Reviewing our activities and using or disclosing medical information in the event that control of our
organization significantly changes.

Working with others (such as lawyers, accountants, and other providers) who assist us to comply
with this Notice and other applicable laws.
In some cases, we may furnish other qualified parties with your medical information for their health care
operations. For example, we may provide your information to a hospital who is evaluating the care its staff
provided to you. If state law requires, we will obtain your permission prior to disclosing your medical
information to other providers or insurers for their health care operations.

4. Persons Involved in Your Care
We may disclose medical information about you to a relative, close personal friend, or any other person
you identify, if that person is involved in your care or payment for your care and the information is relevant
to their involvement and you have agreed, have been given the opportunity to object and do not, or where,
in our professional judgment, it would be in your best interest to disclose the information on your behalf.
For example, we may allow a family member to pick up your prescriptions, medical supplies, or x-rays. We
may also use or disclose information about you to a relative, another person involved in your care, or a
disaster relief organization (such as the Red Cross) as needed to notify someone about your location or
condition. You may ask us at any time not to disclose medical information about you to persons involved in
your care. We will agree to your request and not disclose the information except in certain limited
circumstances, such as emergencies.

5. Required by Law
We will use and disclose medical information about you whenever we are required by law to do so. There
are many state and federal laws that require us to use and disclose medical information. For example, state
law requires us to report known or suspected abuse or neglect to the Department of Social Services. We
will comply with those state laws and with all other applicable laws.

6. Uses and Disclosures Permitted by Law
When permitted by law, we may use or disclose medical information about you for various activities that
are recognized as "national priorities" and other health oversight, public health, and law enforcement
activities. In other words, the government has determined that under certain circumstances (described
below), it is so important to disclose medical information that it is acceptable to do so without the
individual's permission. For more information on these types of disclosures, contact our Corporate Privacy
Officer.

This category of disclosures includes the following:

Threat to health or safety: We may use or disclose medical information about you if we believe, in
good faith, that it is necessary (i) to prevent or lessen a serious threat to health or safety and we
make the disclosure to a person who is reasonably able to prevent or lessen the threat (including a
threatened target); or (ii) for law enforcement authorities to identify or apprehend a person
involved in a crime.

Public health activities: We may use or disclose medical information about you for public health
activities. Public health activities require the use of medical information for various activities,
including, but not limited to, activities related to investigating diseases; reporting abuse and
neglect; monitoring drugs or devices regulated by the Food and Drug Administration; and
monitoring work-related illnesses or injuries. For example, if you have been exposed to a
communicable disease, we may report it to the State and take other actions to prevent the spread of
the disease.

Abuse, neglect, or domestic violence: We may disclose medical information about you to an
appropriate government authority (such as the Department of Social Services) if we reasonably
believe that you may be a victim of abuse, neglect, or domestic violence. Unless such disclosure is
required by law (for example, to report a particular type of injury), we will only make this
disclosure if you agree.

Health oversight activities: We may disclose medical information about you to a health oversight
agency—which is basically an agency responsible for overseeing the health care system or certain
government programs—for activities authorized by law. For example, a government agency may
request information from us while they are investigating possible fraud.

Court proceedings: If you are involved in a lawsuit, we may disclose medical information about
you to a court or an officer of the court (such as an attorney) if we are legally ordered to do so. We
may also disclose medical information about you in response to a subpoena, discovery request, or
other lawful process by someone involved in a legal dispute, but only if reasonable efforts have
been made to notify you of the request or to obtain a court order protecting the information
requested.

Law enforcement: We may disclose medical information about you to a law enforcement official
for specific law enforcement purposes. For example, we may disclose limited medical information
about you to a police officer if the officer needs the information to help find or identify a suspect,
fugitive, or missing person; as required by law, including reporting certain wounds and physical
injuries; if you are the victim of a crime; to alert the officer of a death we believe to be caused by
criminal conduct; information we believe is evidence of a crime occurring on our premises; or, in
emergencies, to report a crime, the location of a crime or victims, or the identity, description, or
location of the perpetrator.

Coroners and others: We may disclose medical information about you to a coroner, medical
examiner, or funeral director or to organizations that help with organ, eye and tissue transplants
for them to carry out their duties and to a personal representative (e.g. the executor of your estate).
We may also release your medical information to a family member or other person who acted as a
personal representative or was involved in your care or payment for care before your death, if
relevant to such person's involvement, unless you have expressed a contrary preference. We are
required to apply safeguards to protect your medical information for 50 years following your death.

Research organizations: We may use or disclose medical information about you to research
organizations if the organization has satisfied certain conditions about protecting the privacy of
medical information.

Certain specialized government functions: We may use or disclose medical information about
you for certain specialized government functions, including, but not limited to, military and
veterans' activities and national security and intelligence activities. If you are taken into custody of
law enforcement, we may disclose medical information about you which is necessary for your
health or the health and safety of others.

7. Business Associates
We may disclose your medical information to our business associates who assist us with our health care
operations and allow them to create, use, maintain, transmit, and disclose such information as necessary to
perform their services for us. For example, we may disclose your medical information to an outside billing
company to assist us in billing insurance companies.

8. Appointment Reminders
We may contact you as a reminder that you have an appointment for treatment or medical services.

9. Treatment Alternatives
We may contact you to provide information about treatment alternatives or other health-related benefits
and services that may be of interest to you.

10. Fundraising
We may contact you as part of a fundraising effort. We may also use, or disclose to a business associate or
to a foundation related to Immanuel, certain information about you, such as your name, address, phone

number, dates of residency or services, and location of residency or services so that we or they may contact
you to raise money for Immanuel. Any time you are contacted for our fundraising purposes, whether in
writing, by phone, or by other means, you will have the opportunity to "opt out" and not receive further
fundraising communications related to the specific fundraising campaign or appeal for which you are being
contacted, unless we have already sent a communication prior to receiving notice of your election to opt
out. You may also opt out of all further fundraising communications. The fundraising communication will
clearly tell you how to opt out.

11. Facility Directory
If permitted by law, we may include your name, location in the facility, general condition, and religious
affiliation in a facility directory. This information may be provided to members of the clergy and, except for
religious affiliation, to other people who ask for you by name. We will not include your information in the
facility directory if you object.

12. Deceased Individuals
We are required to apply safeguards to protect your medical information for 50 years following your death.
Following your death we may disclose medical information to a coroner, medical examiner or funeral
director as necessary for them to carry out their duties and to a personal representative (for example, the
executor of your estate). We may also release your medical information to a family member or other
person who acted as personal representative or was involved in your care or payment for care before your
death, if relevant to such person's involvement, unless you have expressed a contrary preference.

13. Organ, Eye or Tissue Donation
We may release medical information to organ, eye or tissue procurement, transplantation or banking
organizations or entities as necessary to facilitate organ, eye or tissue donation and transplantation.

14. Workers' Compensation
We may release medical information about you as authorized by law for workers' compensation or similar
programs that provide benefits for work-related injury or illness.

15. Incidental Uses and Disclosures
There are certain incidental uses or disclosures of your information that occur while we are providing
service to you or conducting our business. For example, after surgery the nurse or doctor may need to use
your name to identify family members that may be waiting for you in a waiting area. Other individuals
waiting in the same area may hear your name called. We will make reasonable efforts to limit these
incidental uses and disclosures.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
Other than the uses and disclosures described above, we will not use or disclose medical information about
you without the "authorization"—or signed permission—of you or your personal representative. In some
instances, we may wish to use or disclose medical information about you and we may contact you to ask
you to sign an authorization form. In other instances, you may contact us to ask us to disclose medical
information and we will ask you to sign an authorization form. Other disclosures we will make only with
your written authorization include most disclosures of psychotherapy notes made by a mental health
professional during a counseling or therapy session; disclosures for marketing purposes; and a sale of your
medical information to a third party.

If you sign an authorization allowing us to disclose medical information about you, you may later revoke
(or cancel) your authorization in writing, except in very limited circumstances. If you would like to revoke

your authorization, you may write us a letter revoking your authorization or fill out an Authorization
Revocation Form. Authorization Revocation Forms are available from the Corporate Privacy Officer. If you
revoke your authorization, we will follow your instructions, except to the extent that we have already relied
upon your authorization and taken some action.

YOU HAVE RIGHTS WITH RESPECT TO MEDICAL INFORMATION ABOUT YOU
You have several rights with respect to medical information about you. This section of the Notice will
briefly mention each of these rights. If you would like to know more about your rights, please contact our
Corporate Privacy Officer. We will comply with any request to exercise your rights on a timely basis in
accordance with our written policies and as required by law.

1. Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of
this Notice will always be available in the main office of each community, center, or building covered by this
Notice. If you would like to have a copy of our Notice, ask the receptionist for a copy or contact our
Corporate Privacy Officer.

2. Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of medical information about
you that we maintain in certain groups of records. If we maintain your medical records electronically, you
may be able to obtain an electronic copy of your medical records. If we cannot readily produce a copy of
your record for you in the form and format you request, we will produce it in another readable electronic
form we both agree to. You may also instruct us in writing, by clearly designating the recipient and location
for delivery, to send a copy of your medical records to a third party. If you would like to inspect or receive a
copy of medical information about you, you must provide us with a request in writing. You may write us a
letter requesting access or fill out an
Access Request Form. Access Request Forms are available from our
Corporate Privacy Officer.

We may deny your request in certain circumstances. If we deny your request, we will explain our reason
for doing so in writing. We will also inform you in writing if you have the right to have our decision
reviewed by another person.

If you would like a copy of the medical information about you, we will charge you a cost-based fee to
produce the copies. These fees are outlined in your Resident or Participant Handbook. We may be able to
provide you with a summary or explanation of the information. Contact our Corporate Privacy Officer for
more information on these services and any possible additional fees.

3. Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical information about you
that we maintain in certain groups of records. If you believe that we have information that is either
inaccurate or incomplete, we may amend the information to indicate the problem and notify others who
have copies of the inaccurate or incomplete information. If you would like us to amend information, you
must provide us with a request in writing and explain why you would like us to amend the information. You
may either write us a letter requesting an amendment or fill out an
Amendment Request Form.
Amendment Request Forms are available from our Corporate Privacy Officer.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason
for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree

with our decision to deny your amendment request and we will share your statement whenever we
disclose the information in the future.

4. Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of certain disclosures of your
medical information that we have made for the previous six (6) years. If you would like to receive an
accounting, you may send us a letter requesting an accounting, fill out an
Accounting Request Form, or
contact our Corporate Privacy Officer. Accounting Request Forms are available from our Corporate Privacy
Officer. The accounting will not include several types of disclosures, including disclosures for treatment,
payment, or health care operations, or disclosures made with your authorization. If you request an
accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of
preparing the accounting.

5. Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of medical information about you for
treatment, payment, and health care operations, or to persons involved in your care. We are not required to
agree to your request, and unless the following exception applies, we will notify you if we are unable to do
so. In addition, we may cancel a restriction (except those described below) at any time as long as we notify
you of the cancellation and continue to apply the restriction to information collected before the
cancellation.
Under federal law, we must agree to your requested restriction(s) if:
a. Disclosure is to a health plan for the purpose of carrying out payment or health care operations
purposes (and is not for purposes of carrying out treatment);
b. Disclosure is not otherwise required by law; and,
c. The medical information pertains solely to a health care item or service for which the health care
provider involved has been paid out-of-pocket in full.
Such a restriction will only apply to records that relate solely to the service for which you have paid in full.
Once we agree to your request, we must follow your restrictions (except if the information is necessary for
emergency treatment). You may cancel the restrictions at any time, and if you subsequently authorize us to
disclose all of your health information to your health plan after the date of your requested restriction, we
will assume you have withdrawn your request for restriction.
Several different covered entities listed at the start of this Notice use this Notice. You must make a separate
request to each covered entity from whom you will receive services that are involved in your request for
any type of restriction. Contact Immanuel at the address listed below if you have questions regarding
which providers will be involved in your care.

6. Right to Request an Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different method. For example,
you may prefer to have all written information mailed to your work address rather than to your home
address.

We will agree to any reasonable request for alternative methods of contact. If you would like to request an
alternative method of contact, you must provide us with a request in writing. You may write us a letter or
fill out an
Alternative Contact Request Form. Alternative Contact Request Forms are available from our
Corporate Privacy Officer.

7. Notification in the Case of Breach
DOCS/1183117.4
We are required by law to notify you of a breach of your unsecured medical information. We will provide
such notice to you without unreasonable delay, but in no case later than 60 days after we discover the
breach.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies
or procedures, you may file a written complaint either with us or with the federal government.

We will not take any action against you or change our treatment of you in any way if you file a
complaint.

To file a written complaint with us, you may bring your complaint directly to our Corporate Privacy Officer:
Immanuel
Attn: Corporate Privacy Officer
1044 North 115th Street , Suite 500
Omaha, NE 68154
402-829-5573 or 1-855-829-5573 (toll free)
Email: privacyofficer@immanuelcommunities.org

To file a written complaint with the federal government, please use the following contact information:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html

Effective date of this Notice: December 5, 2016.

NOTICE OF NONDISCRIMINATION
Immanuel and its affiliates comply with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Immanuel does not exclude people or
treat them differently because of race, color, national origin, age, disability, or sex.
Immanuel:

Provides free aids and services to people with disabilities to communicate effectively with us,
such as:

o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,
other formats)

Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages

If you need these services, contact Annette Miller, Immanuel’s Civil Rights Coordinator.
If you believe that Immanuel has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Annette Miller,
Corporate Compliance Officer and Civil Rights Coordinator, 1044 North 115
th Street, Suite 500, Omaha,
NE 68154, 855-829-5573, 1-800-833-7352 (TTY- Nebraska) or 1-800-735-2942 (TTY- Iowa), (402)
829-2939 (fax), ComplianceOfficer@immanuel.com. You can file a grievance in person or by mail, fax,
or email. If you need help filing a grievance, Annette Miller, Civil Rights Coordinator, is available to
help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW, Room 590F,
HHH Building,
Washington, DC 20201
1-800-368-1019
800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


PACE Iowa, PACE Nebraska, Immanuel Affordable II, Inc., Immanuel Retirement Communities (Trinity Village Assisted Living only),
and Immanuel Long Term Care.


Español (Spanish)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame
al 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).

繁體中文 (Chinese)
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-844-525-7490Nebraska
TTY:1-800-833-7352/ Iowa TTY: 1-800-735-2942).

Tiếng Việt (Vietnamese)
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525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).

Srpsko-hrvatski (Serbo-Croatian)
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 1-844-525-7490 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: Nebraska TTY: 1-
800-833-7352/ Iowa TTY: 1-800-735-2942).

Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-
2942).

ال عرب ية )(Arabic
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم ( 0947-525-448-1رقم
.)2492-537-008-1 awoI/2537-338-008-1 aksarbeN:هاتف الصم والبكم

ພາສາລາວ (Lao)
ໂປດຊາບ: ຖ ້ າວ ່ າ ທ ່ ານເວ ້ າພາສາ ລາວ, ການໍບິລການຊ ່ ວຍເຫ ຼ ອດ ້ ານພາສາ, ໂດຍໍ່ບເສ ັ ຽຄ ່ າ,
ແມ ່ ນມ ີ ພ ້ ອມໃຫ ້ ທ ່ ານ. ໂທຣ 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-
2942).

한국어 (Korean)
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-
525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942)

번으로 전화해 주십시오.
unD (Karen)
1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).

Français (French)
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-844-525-7490 (Nebraska ATS: 1-800-833-7352/ Iowa ATS: 1-800-735-
2942).

Oroomiffa (Oromo)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni
argama. Bilbilaa 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).

ह िदी (Hindi)
धयान दे: यहद आप ह िदी बोलते ै तो आपके ललए मुफत मे भाषा स ायता सेवाएि उपलबध ै। 1-844-525-
7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).
पर कॉल करे।

Deitsch (Pennsylvania Dutch)
Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber
gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-844-525-7490 (Nebraska
TTY: 1-800-833-7352/ Iowa TTY: 1-800-735-2942).

ภาษาไทย (Thai)
เรียน: ถา ้ คุณพด ู ภาษาไทยคุณสามารถใชบ ้ ริการช่วยเหลือทางภาษาไดฟ ้ รี โทร 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/
Iowa TTY: 1-800-735-2942).

Tagalog (Tagalog – Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa 1-844-525-7490 (Nebraska TTY: 1-800-833-7352/ Iowa TTY:
1-800-735-2942).