Privacy, Compliance, Disclosure Forms and Admissions Agreement

Methodist Home for Nursing and Rehabilitation

Summary – Notice of Privacy Practices

This is a summary of our Notice of Privacy Practices which describes how medical information about you may be used and disclosed and how you can get access to this information. You can obtain a full version of this notice from the Admission Office, Privacy Officer or on our website @


  • To provide you with medical treatment and services;
  • To bill and receive payment for the care given to you;
  • For functions necessary to run our facility and to assure that our residents receive quality care;
  • For workers’ compensation or similar programs;
  • For required public health activities (e.g., reporting abuse or adverse reactions to medication);
  • For law enforcement in certain limited circumstances;
  • To a coroner, medical examiner or funeral director as required by law;
  • For organ procurement or transplantation, if you are a potential donor.


We are required to:

  • Maintain the privacy of your health information;
  • Provide you with a notice of our legal duties and privacy practices;
  • Follow the terms of our Notice of Privacy Practices;
  • Notify you if we can’t agree to your requested restrictions;
  • Notify you in writing if there is a significant breach of your health information, as defined in the HITECH privacy breach notification.


You have the right to:

  • To inspect and get a copy of your paper or electronic medical record;
  • To request restrictions on certain uses and disclosures of your medical information;
  • To revoke your authorization to disclose health information;
  • To request an accounting of our disclosure of your medical information;
  • To request an amendment to your paper or electronic medical record;
  • To request that we communicate with you in certain way or at a certain location;
  • To receive a full copy of our Notice of Privacy Practices
  • To opt-out of Fundraising or Marketing communications.

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer at (718) 548-5100 x235. You also may file a complaint directly with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate in any way if you choose to file a complaint with us or the OCR.

Revised 9/23/13; 8/30/17

Confidential  AND  Privileged Information

Materials included herein must be maintained by the Compliance Committee as confidential and filed in a manner which will not result in the release of such information to third parties or other employees who are not considered necessary to the subject matter.

Methodist Church Home
  • Part 1. Personal Details

  • MM slash DD slash YYYY
  • Part 2. Anonymous Complaints:

    • If you are an Employee, Vendor or Agent and wish to remain anonymous, please detail your complaint or allegation of violation below without including the identifying information requested in Box 1. Please be aware that the failure to provide specific information may impede the full and complete investigation of this matter.
    • This form will be completed by the Compliance Officer for Verbal complaints or those submitted in other media (email, mail, voice message, etc.)
    • To ensure employee cooperation, the Methodist Church Home will not take any retaliatory action or retribution against any employee who has submitted a report of a suspected violation or who has participated in an investigation of a suspected violation in good faith. Any employee who takes retaliatory action or retribution against another employee who has either reported a suspected violation or participated in an investigation of a suspected violation will be subject to disciplinary action.
  • Part 3. Summary of Complaint/Violation

  • Part 4. Additional Detail

  • Additional Detail

    • Provide dates, location and/or other specifics regarding the complaint or allegations

    Names of Individuals or Entities Involved

    • Provide names, if known of alleged violators or those individuals or entities who you may know have information about the matter
  • Part 5. Alternative Contact

  • After filling out this Form, you may print, sign and mail this form to:

    Methodist Church Home - Compliance Officer
    4499 Manhattan College Parkway
    Bronx, NY 10471-3998

    Or Submit by signing electronically below.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

Required Disclosures & Admissions Information

Methodist Home for Nursing and Rehabilitation

Required Disclosures

You can view or download our disclosure form and vendor summary.

Admissions Agreement

You can view, download and print the Admissions Agreement.

This is a resource page designed to address any necessary documentation needed to clarify policy with regards to the Methodist Home for Nursing and Rehabilitation. For any further clarification, please contact us directly at: (718) 548-5100.

What to Expect When Visiting Methodist Home for Nursing and Rehabilitation