HERITAGE HOSPICE, INC.
NOTICE OF HOSPICE 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
Heritage Hospice, Inc. 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. The 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. The Hospice may use your health information to coordinate care within the
Hospice and with others involved in your care, such as your attending physician, members of the Hospice
interdisciplinary team and other health care professionals who have agreed to assist the Hospice in coordinating
care. For example, physicians involved in your care will need information about your symptoms in order to
prescribe appropriate medications. The Hospice also may disclose your health care information to individuals
outside of the Hospice involved in your care including family members, clergy who you have designated,
pharmacists, suppliers of medical equipment or other health care professionals.
To Obtain Payment. The Hospice may include your health information in invoices to collect payment
from third parties for the care you receive from the Hospice. For example, the Hospice may be required by your
health insurer to provide information regarding your health care status so that the insurer will reimburse you or
the Hospice. The 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. The Hospice may use and disclose health information for its
own operations in order to facilitate the function of the Hospice and as necessary to provide quality care to all of
the 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 the 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 Fundraising Activities. The Hospice may elect to use information about you, upon
obtaining written explanation/and authorization from you, for fundraising purposes.
For Appointment Reminders. The 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. The 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. 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. The 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. The Hospice is allowed to notify government
authorities if the Hospice believes a patient is the victim of abuse, neglect or domestic violence. The 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. The 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. The 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. The 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 the 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, the 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 the Hospice has a suspicion that your death was the result of
criminal conduct including criminal conduct at the Hospice.
- In an emergency in order to report a crime.
To Coroners And Medical Examiners. The 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. The 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, the Hospice may disclose your health information prior to and in reasonable
anticipation of your death.
For Organ, Eye Or Tissue Donation. The 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. The Hospice may, under very select circumstances, use your health
information for research. Before the 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. The Hospice may, consistent with applicable
law and ethical standards of conduct, disclose your health information if the 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 the
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 is stated above, the Hospice will not disclose your health information other than with your
written authorization. If you or your representative authorizes the 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 the 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 the Hospice ‘s disclosure of your
health information to someone who is involved in your care or the payment of your care. However,
the Hospice is not required to agree to your request. If you wish to make a request for restrictions,
please contact The Director of Patient Services.
- Right to receive confidential communications. You have the right to request that the Hospice
communicate with you in a certain way. For example, you may ask that the 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 Director
of Patient Services, 859-236-2425. The 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 The Director of Patient Services, 859-236-2425. If you request
a copy of your health information, the 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
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 the Hospice. A
request for an amendment of records must be made in writing to The Director of Patient Services,
P.O. Box 1213, Danville, KY 40423. The 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 the Hospice, if the records you are requesting are not part
of the 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 the
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 the 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 The Director of
Patient Services, P.O. Box 1213, Danville, KY 40423. 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 representative 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 The Director of Patient Services,
859-236-2425.
DUTIES OF THE HOSPICE
The 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. The Hospice is required to abide by the
terms of this Notice as may be amended from time to time. The 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 the
Hospice changes its Notice, the 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 the Hospice and to the
Secretary of DHHS if you or your representative believe that your privacy rights have been violated. Any
complaints to the Hospice should be made in writing to Director of Patient Services.. The 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
The Hospice has designated the Director of Patient Services as its contact person for all issues
regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at:
Heritage Hospice, Inc.
P.O. Box 1213
Danville, KY 40423
859-236-2425
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Director of Patient Services
Heritage Hospice, Inc.
P.O. Box 1213
Danville, KY 40423
859-236-2425
or
Regional Manager
Office for Civil Rights
Department of Health and Human Service
233 North Michigan Ave. Ste #240
Chicago, IL 60601
Dev: 04/03
Revised: 06/05
