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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.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES
UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND
DISCLOSED:
To
Provide Treatment. Hospice may use your health information to coordinate care
within Hospice and with others involved in your care, such as your attending
physician, members of Hospice interdisciplinary team and other health care
professionals who have agreed to assist Hospice in coordinating care. For example, physicians involved in your care will need information about
your symptoms in order to prescribe appropriate medications. Hospice also may disclose your health care information to individuals
outside of Hospice involved in your care including family members, clergy who
you have designated, pharmacists, ambulance services, suppliers of medical
equipment or other health care professionals.
To Obtain Payment. Hospice may include your health information in invoices to collect payment from third parties for the care you receive. For example, Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse Hospice. Hospice also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for hospice care and the services that will be provided to you. To
Conduct Health Care Operations. Hospice may use and disclose health information for its own operations in
order to facilitate the function of Hospice and as necessary to provide quality
care to all of Hospice’s patients. Health
care operations includes such activities as:
§ Quality assessment and improvement activities. § Protocol
development, case management and care coordination.
§ Contacting
health care providers and patients with information about treatment alternatives
and other related functions that do not include treatment.
§ Professional
review and performance evaluation.
§ Training
programs including those in which students, trainees or practitioners in health
care learn under supervision.
§ Training
of non-health care professionals.
§ Accreditation, certification, licensing or credentialing activities. § Review and
auditing, including compliance reviews, medical reviews, legal services and
compliance programs.
§ Business
management and general administrative activities of Hospice.
§ Fundraising
for the benefit of Hospice.
For
example, Hospice may use your health
information to evaluate its staff performance, combine your health information
with other Hospice patients in evaluating how to more effectively serve all
Hospice patients, disclose your health information to Hospice staff and contracted personnel for training
purposes, use your health information to contact you as a reminder regarding a
visit to you, or contact you as part of general fundraising and community
information mailings (unless you tell us you do not want to be contacted).
For
Appointment Reminders. Hospice may use and disclose your health information to
contact you as a reminder that you have an appointment for a home visit.
For
Treatment Alternatives. Hospice may use and disclose your health information to tell
you about or recommend possible treatment options or alternatives that may be of
interest to you.
When
Legally Required. The Hospice will disclose your health information when it is required to
do so by any Federal, State or local law.
When
There Are Risks to Public Health. Hospice may disclose your health information for public
activities and purposes in order to:
§ Prevent or
control disease, injury or disability, report disease, injury, vital events such
as birth or death and the conduct of public health surveillance, investigations
and interventions.
§ Report
adverse events, product defects, to track products or enable product recalls,
repairs and replacements and to conduct post-marketing surveillance and
compliance with requirements of the Food and Drug Administration.
§ Notify a
person who has been exposed to a communicable disease or who may be at risk of
contracting or spreading a disease.
To
Report Abuse, Neglect Or Domestic Violence. Hospice is required to
notify government authorities if Hospice
believes a patient is the victim of abuse, neglect or domestic violence. Hospice will make this disclosure only when specifically required or
authorized by law or when the patient agrees to the disclosure.
To
Conduct Health Oversight Activities. Hospice may disclose your health information to a health oversight entity
for activities including audits, civil administrative or criminal
investigations, inspections, licensure or disciplinary action. Hospice, however, may not disclose your health information if you are the
subject of an investigation and your health information is not directly related
to your receipt of health care or public benefits.
In
Connection With Judicial And Administrative Proceedings. Hospice
may disclose your health information in the course of any judicial or
administrative proceeding in response to an order of a court or administrative
tribunal as expressly authorized by such order or in response to a subpoena,
discovery request or other lawful process, but only when Hospice makes
reasonable efforts to either notify you about the request or to obtain an order
protecting your health information.
For
Law Enforcement Purposes. As permitted or required by State law, Hospice may disclose
your health information to a law enforcement official for certain law
enforcement purposes as follows:
§ As
required by law for reporting of certain types of wounds or other physical
injuries pursuant to the court order, warrant, subpoena or summons or similar
process.
§ For the
purpose of identifying or locating a suspect, fugitive, material witness or
missing person.
§ Under
certain limited circumstances, when you are the victim of a crime.
§ To a law
enforcement official if Hospice has a suspicion that your death was the result
of criminal conduct including criminal conduct at Hospice.
§ In an
emergency in order to report a crime.
To
Coroners And Medical Examiners. Hospice may disclose your health information to coroners and medical
examiners for purposes of determining your cause of death or for other duties,
as authorized by law.
To
Funeral Directors. Hospice may disclose your health information to funeral
directors consistent with applicable law and if necessary, to carry out their
duties with respect to your funeral arrangements. If necessary to carry out their duties, Hospice may disclose your health
information prior to and in reasonable anticipation of your death.
For
Organ, Eye Or Tissue Donation. Hospice may use or disclose your health information to organ procurement
organizations or other entities engaged in the procurement, banking or
transplantation of organs, eyes or tissue for the purpose of facilitating the
donation and transplantation.
For
Research Purposes. Hospice may, under very select circumstances, use your health
information for research project that will have been subject to an extensive
approval process.
In
the Event of A Serious Threat To Health Or Safety. Hospice
may, consistent with applicable law and ethical standards of conduct, disclose
your health information if Hospice, in good faith, believes that such disclosure
is necessary to prevent or lessen a serious and imminent threat to your health
or safety or to the health and safety of the public.
For
Specified Government Functions. In certain circumstances, the Federal regulations authorize Hospice to
use or disclose your health information to facilitate specified government
functions relating to military and veterans, national security and intelligence
activities, protective services for the President and others, medical
suitability determinations and inmates and law enforcement custody.
For
Worker's Compensation. The Hospice may release your health information for worker's
compensation or similar programs.
AUTHORIZATION
TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, Hospice will not disclose your health information other than with your written authorization. If you or your representative authorizes Hospice to use or disclose your health information, you may revoke that authorization in writing at any time. YOUR RIGHTS
WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health
information that Hospice maintains:
Right
to request restrictions. You may request restrictions on certain uses and disclosures
of your health information. You
have the right to request a limit on Hospice ‘s disclosure of your health
information to someone who is involved in your care or payment for your care. However, Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the
Privacy Officer 740-283-7487 or toll-free 877-467-7423.
Right
to receive confidential communications. You have the right to
request that Hospice communicate with you in a certain way. For example, you may ask that Hospice only conduct
communications pertaining to your health information with you privately with no
other family members present. If
you wish to receive confidential communications, please contact the Privacy
Officer 740-283-7487 or toll-free 877-467-7423. Hospice will not request that you provide any reasons for your
request and will attempt to honor your reasonable requests for confidential
communications.
Right
to access your health information. You have the right to inspect and copy your health information, including
billing records. A request to
inspect and copy records containing your health information must be made in
writing to the Privacy Officer 740-283-7487 or toll-free 877-467-7423. You may contact the Privacy Officer for a request form. If you request a copy of your health information, Hospice may charge a
reasonable fee for copying and assembling costs associated with your request.
Right
to amend health care information. You or your representative have the right to request that Hospice amend
your records, if you believe that your health information is incorrect or
incomplete. That request may be
made as long as the information is maintained by Hospice. A request for an amendment of records must be made in writing to Valley
Hospice Privacy Officer, 380 Summit Avenue, Steubenville, Ohio 43952. Hospice may deny the request if it is not in writing or does not include
a reason for the amendment. The
request also may be denied if your health information records were not created
by Hospice, if the records you are requesting are not part of Hospice‘s
records, if the health information you wish to amend is not part of the health
information you or your representative are permitted to inspect and copy, or if,
in the opinion of Hospice, the records containing your health information are
accurate and complete.
Right
to an accounting. You or your representative have the right to request an
accounting of disclosures of your health information made by Hospice for certain
reasons, including reasons related to public purposes authorized by law and
certain research. The request for an accounting must be made in writing to
Valley Hospice Privacy Officer, 380 Summit Avenue, Steubenville, Ohio 43952. The request should specify the time period for the accounting starting on
or after April 14, 2003. Accounting
requests may not be made for periods of time in excess of six (6) years. Hospice would provide the first accounting you request during any
12-month period without charge. Subsequent
accounting requests may be subject to a reasonable cost-based fee.
Right
to a paper copy of this notice. You or your representative have the right to a separate paper copy of
this Notice at any time even if a copy has been previously received. To obtain a separate paper copy, please contact the Privacy Officer
740-283-7487 or toll-free 877-467-7423.
DUTIES OF HOSPICE
Hospice
is required by law to maintain the privacy of your health information and to
provide to you and your representative this Notice of its duties and privacy
practices. Hospice is required to
abide by the terms of this Notice as may be amended from time to time. Hospice reserves the right to change the terms of its Notice and to make
the new Notice provisions effective for all health information that it
maintains. If Hospice changes its
Notice, you or your representative will receive a revised copy.
You or your personal representative have the right to
express complaints to Hospice and to the Secretary of DHHS if you or your
representative believe that your privacy rights have been violated. Any complaints to Hospice should be made in writing to Valley Hospice
Privacy Officer, 380 Summit Avenue, Steubenville, Ohio 43952. Hospice encourages you to express any concerns you may have regarding the
privacy of your information. You
will not be retaliated against in any way for filing a complaint.
Effective Date
This
Notice is effective on April 14, 2003.
CONTACT
PERSON
Hospice
has designated the Privacy Officer as the contact person for all issues regarding
patient privacy and your rights under the Federal privacy standards. You may contact this person at:
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