| HOSPICE
Serving Davis and Wapello Counties
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.
USE AND DISCLOSURE OF HEALTH INFORMATION
Hospice may use your health information, information that constitutes
protected health information as defined in the Privacy Rule of the
Administrative Simplification provisions of the Health Insurance
Portability and Accountability Act of 1996, for purposes of providing
you treatment, obtaining payment for your care and conducting health
care operations. Hospice has established policies to guard against
unnecessary disclosure of your health information.
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 the Hospice interdisciplinary team (IDT) 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, suppliers of medical
equipment or other health care professionals.
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.
• Activities designed to improve health or reduce health care
costs.
• 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 planning and development including cost management
and planning related analyses and formulary development.
• Business management and general administrative activities
of the Hospice.
• Fundraising for the benefit of the 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).
If you reside in a Hospice’s inpatient facility; certain
information may be disclosed to people who ask for you by name.
This would include, but is not limited to, your general health status,
your religious affiliation and which room you occupy in the Hospice
inpatient facility. Please inform Hospice staff if you do not want
your information to be included.
To Obtain Payment. Hospice may include your
health information in invoices to collect payment from third parties
for the care you receive from Hospice For example, Hospice may be required by your health insurer to provide information
regarding your health care status so that the insurer will reimburse
you or 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.
For Fundraising Activities. Hospice
may use information about you including your name, address, phone
number and the dates you received care in order to contact you or
your family to raise money for Hospice If you do not want
Hospice to contact you or your family, notify Suzanne Anderson,
Executive Director, Hospice , 312 E. Alta Vista Ave., Ottumwa,
IA, 52501,
641-682-0684, 1-800-806-4967 and indicate that you do not wish 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.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH
AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED
AND DISCLOSED.
When Legally Required. 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.
• Notify an employer about an individual who is a member
of the workforce as legally required.
To Report Abuse, Neglect Or Domestic Violence.
Hospice is allowed 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
hospice 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
are 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 suspects
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. Before Hospice discloses any of your health information
for such research purposes; the project will be 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. Hospice
may release your health information for worker's compensation or
similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is 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 the payment of your care. However, Hospice is not
required to agree to your request. If you wish to make a request
for restrictions, please contact Suzanne Anderson, Executive Director,
Hospice, 312 E. Alta Vista Ave., Ottumwa, IA 52501, 641-682-0684,
1-800-806-4967.
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 Suzanne Anderson, Executive Director,
Hospice, 312 E. Alta Vista Ave., Ottumwa, IA 52501,
641-682-0684,
1-800-806-4967. 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 inspect and copy 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 may be made to Suzanne Anderson, Executive
Director, Hospice, 312 E. Alta Vista Ave., Ottumwa, IA 52501, 641-682-0684,
1-800-806-4967. 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 representatives have the right to request that the 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 Suzanne Anderson, Executive Director,
Hospice, 312 E. Alta Vista Ave., Ottumwa, IA 52501. 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 Suzanne Anderson, Executive Director, Hospice, 312 E. Alta Vista Ave., Ottumwa,
IA 52501. 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. The 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 representatives have a right to a separate paper copy of
this Notice at any time even if you or your representative have
received this Notice previously. To obtain a separate paper copy,
please contact Suzanne Anderson, Executive Director, Hospice, 312 E.
Alta Vista Ave., Ottumwa, IA 52501, 641-682-0684, 1-800-806-4967.
The patient or a patient’s representative may also obtain
a copy of the current version of Hospice’s Notice of Privacy
Practices at its website, www.hospice-ottumwa.com.
DUTIES OF THE 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, Hospice will provide
a copy of the revised Notice to you or your appointed representative.
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 Suzanne Anderson, Executive Director,
Hospice, 312 E. Alta Vista Ave., Ottumwa, IA 52501. 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.
CONTACT PERSON
Hospice has designated Suzanne Anderson, as the Privacy
Officer and its contact person for all issues regarding patient
privacy and your rights under the Federal privacy standards. You
may contact her at:
Suzanne Anderson, Executive Director
Hospice
312 E. Alta Vista Avenue
Ottumwa, IA 52501
Phone: (641) 682-0684 or 1-800-806-4967
EFFECTIVE DATE: This Notice is effective
February 6, 2006
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE
CONTACT Suzanne Anderson via phone at (641) 682-0684 or 1-800-806-4967.
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