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Foundations Senior Service

Effective 10/1/2022


Foundations Senior Services Inc (FSSI ) is committed to protecting your privacy and understands the importance of safeguarding medical information. We are required by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your protected health information (PHI) that identifies you or could be used to identify you. HIPAA also requires that we provide you with this Notice of Privacy Practices which explains our legal duties, our privacy practices and your rights regarding the PHI that FSSI collects and maintains about you. In addition, state law requires that we provide you with a state notice that explains how FSSI can use or disclose your nonpublic personal financial information and describes your rights regarding this information.


This section explains the RIGHTS you have regarding your PHI and our obligations regarding these rights.

You can exercise these rights by submitting a written request to us – the contact information is at the end of this notice.

Right to request a copy of your PHI

  • You can request to see or get a copy of your PHI contained in a designated record set.

  • We have 30 days to fulfill your request, however, we can receive an additional 30 days if needed. We can charge a reasonable, cost-based fee to cover the costs of fulfilling your request.

  • We can deny your request in some situations. We will explain the reason for the denial in the response we send you and you have a right to have this decision reviewed.

Right to request an amendment to your PHI

  • You can request an amendment to your PHI in a designated record if you believe it is incorrect or incomplete.

  • We have 60 days to respond to your request, however, we can receive an additional 30- days if needed.

  • We can deny your request, for example if we determine that your PHI is correct and complete or that we did not create the PHI. We will explain the reason for the denial in the response we send you and you have a right to submit a statement of disagreement

Right to request confidential communications

  • You can request that we contact you in a specific way or at an alternative address.

  • We are required to accommodate reasonable requests; however, we do have the right to ask you for information about how your payment will be handled as well as specifics about your communication alternatives.

Right to request that we limit what we can use or share

  • You can request that we do not share or use some of your PHI for purposes of treatment, payment, and our operations.

  • You can also request that we do not share some of your PHI to family members or friends who may be involved in your care or for purposes of notification as described in this notice.The request must be specific and state the reason for the restriction and to whom you want the restriction to apply. We can deny your restriction request; however, we must honor your request if the release of your PHI is related to (1) payment or health care operations and is not otherwise required by law, and/or (2) a health care item or service which you paid for in full yourself.

  •  If we agree to the restriction request, we can’t disclose your PHI unless the PHI needs to be disclosed for emergency treatment.

Right to request a list of individuals or entities who received your PHI

  • You can request an accounting of disclosures which is a list of all the disclosures we made during the six years prior to your request date. The list will not contain all disclosures made for treatment, payment, health care operations as well as a couple of other situations (details about these situations are described later in the notice).

  • You can request 1 accounting in any 12-month period - if you request additional ones in this time frame, we may charge a reasonable cost-based fee. We will notify you before charging you - you can then withdraw or modify your request to avoid a fee.

  • We have 60 days to respond to your request; however, we have an additional 30 days if needed.

Right to request a copy of the Notice


  • You can request a paper copy of this notice at any time. To request a copy, submit your written request using the contact information at the end of this notice

Right to choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, this individual can act on your behalf and make choices for you.

  • We will confirm that this individual has the right to act on your behalf before we release any of your PHI.

Right to file a complaint

  • You can file a complaint directly with us if you believe we have violated your privacy rights by using the contact information at the end of this notice.

  • You can also file a complaint with the Secretary of U.S. Department of Health and Human Services Office for Civil Rights by calling 1-877-696-6775; or by visiting or by sending a letter to them at: 200 Independence Ave., SW, Washington, D.C. 20201.

  • We will not retaliate against you in any way for filing a complaint.

This section explains when we must receive your consent before sharing your PHI.

We can share your PHI for these purposes with your verbal or written consent

  • You can identify a relative, close friend, or other person to help you with your care decisions; we will disclose limited PHI needed to that person to assist you. (If you are unable to give your consent and we determine in our professional judgement that it is in your best interest, we can use or disclose your PHI to assist in notifying a family member, personal representative or other person that can help you.)

  • For our fundraising efforts

We cannot use or disclose PHI for these purposes without your written consent.

  • To conduct marketing or for our financial benefit

  • Release psychotherapy notes

There may be other uses and disclosures of your PHI beyond those listed that may require your authorization if the use or disclosure is not permitted or required by law.
You have the right to revoke your authorization, in writing at any time except to the extent that we have already used or disclosed your PHI based on that initial authorization

This section describes the situations where we are permitted by federal laws to use or share your PHI.

Although not exhaustive, it will give you a good idea of the types of routine uses and disclosures we make

Manage and support the health care you receive

  • We can use your PHI and share it with the health professionals who are treating you, for example, when your provider sends us information about your diagnosis and
    treatment plan so we can arrange for additional services

Run our organization

  • We can use and disclose your PHI to help us manage our business operations and fulfill our obligations to our customers and members, for example, we use PHI for enrollment, health care programs, activities related to the creation, renewal, or replacement of a health plan, and development of better high quality healthcare services. (We can’t use genetic information to deny or refuse an individual health plan coverage).

Pay for your health services

  • We can use and disclose your health information to process your claims and pay your provider, for example, when we share information about you to coordinate benefits between your dental plan and our medical plan.

Administer your plan

  • We may disclose your health information to your health plan sponsor for plan administration purposes, for example, if your company contracts with us to provide their group health plan, we may need to provide them certain statistics to explain the premiums we charge.

The following are examples of when we are permitted to use or disclose your PHI without authorization and without your ability to object to its use or disclosure

Public health activities

  • We are permitted to disclose PHI for public health purposes. This includes disclosures to a public health authority or other government agency that has the authority to collect and receive such information (e.g., the Food and Drug Administration).

Health oversight activities

  • We can use or disclose your PHI to the extent that it is required by federal, state, or local laws for health oversight

Abuse, neglect, or serious threat to health or safety

  • We can disclose PHI to a government agency or public health authority authorized by law to receive information about adults and children who are victims of abuse, neglect, or domestic violence.

  • We also can disclose PHI, if in our professional opinion it is necessary to prevent a serious and imminent threat to the public health or safety; however, the PHI can only be disclosed to someone that we reasonably believe can prevent or lessen the threat.

Research Initiatives

  • In certain situations, we are permitted to disclose a limited data set for research purposes

Required by the Secretary of Health and Human Services

  • We may be required to disclose PHI to the Secretary of Health and Human Services so that they can determine our compliance with the requirements of the final rule related to the Standards for Privacy of Individually Identifiable Health Information.

Comply with the law

  • In some situations, we may be required by applicable federal, state, or local law to disclose your PHI

Organ donors, coroners and funeral directors

  • If you are an organ donor, we may disclose your PHI to an organ procurement organization if needed to facilitate organ donation or transplantation.

  • We may disclose your PHI if it is needed by a medical examiner, coroner, or funeral director to perform legally authorized duties

Workers’ Compensation

  • We may be required to share PHI to comply with workers compensation laws and other similar programs

Specialized Government Functions; National Security and Intelligence Activities

  • We may be asked to disclose PHI in certain situations such as determining eligibility for benefits offered by the Department of Veterans Affairs.

  • We may also be required by law to disclose PHI to authorized federal officials for national security concerns, intelligence or counterintelligence activities, the protection of the President, and other authorized persons or foreign heads of state as may be required by law.

Respond to lawsuits and legal actions

  • We may disclose your PHI in response to an administrative or court order but only if  the disclosure is expressly authorized.

  • We may also be required to disclose PHI to respond to a subpoena, discovery request,

  • or other similar request

Law enforcement

  • We may disclose PHI, if the applicable legal requirements are met, to law enforcement for the purposes of responding to a crime.


  • We may use or disclose the PHI we created or received in the course of paying for the healthcare services of inmates in a correctional facility.

Business Associates

  • We may disclose PHI to a Business Associate which is an entity or person that performs activities or services on our behalf that involve the use, disclosure, access, creation, or storage of PHI. We require a Business Associate to execute appropriate agreements
    before they initiate these activities or services

Additional Health information

  • Some federal or state laws include additional requirements for the use or disclosure of certain health condition related information. We follow the applicable requirements of these laws


We also have the following responsibilities and legal obligations to:

  • Maintain the privacy and security of your PHI.

  • Notify you in the event you are affected by a breach of unsecured PHI.

  • Provide you with a paper copy of this notice upon request.

  • Abide by the terms of this current notice.

  • Refrain from using or disclosing PHI in any manner not described in this notice unless you authorize us to do so in writing


Effective 10/1/2022

Foundations Senior Services Inc  collects nonpublic personal information about you from your insurance application, healthcare claims, payment information and consumer reporting agencies. FSSI will:



  • Not disclose this information, even if your customer relationship with us ends, to any non-affiliated third parties except with your consent or as permitted by law.

  • Restrict access to this information to only those employees who perform functions necessary to administer our business and provide services to our customers.

  • Maintain security and privacy practices that include physical, technical, and administrative safeguards to protect this information from unauthorized access.

  • Use this information for the sole purpose of administering your insurance plan, processing you claims, ensure proper billing, provide you with customer service and comply with the law.

  • Only share this information as required or permitted by law and if needed with the following third parties:

  • Company affiliates

  • Business partners that provide services on our behalf (i.e., claims management, marketing, clinical support

  • Insurance brokers or agents, financial services firms, stop-loss carriers

  • Regulatory, governmental and law enforcement agencies

  • Your Employer Group Health plan.


You also have the right to ask what nonpublic financial information we have about you and to request a copy of it


REVIEWED: August 2022

We reserve the right to change the privacy practices described in these notices and make the new practices apply to all the PHI we maintain about you. Should we make a change, we will post the revised notices on our website. You can always request a paper copy using the contact information below. Depending on the changes made to
the Notice, we may be required by applicable law to mail you a copy

REVIEWED: August 2022

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Foundations Senior Services Inc complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Foundations Senior Services Inc does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Foundations Senior Services Inc:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
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:
Qualified interpreters
Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that Foundations Senior Services Inc 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: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960. You can file a grievance by phone, mail, or fax. If you need help filing a grievance, a 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, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at

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