|
NOTICE OF
PRIVACY PRACTICES
HIPAA
EFFECTIVE DATE April 14, 2003
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 of the Rock River
Valley 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.
-
Memorial Service.
-
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 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 the Hospice. The Hospice may
also release this information to a related Hospice foundation. If you do
not want the Hospice to contact you or your family, notify the Executive
Director, Hospice of the Rock River Valley, 815 288-3673, and indicate that
you do not wish to be contacted.
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 Executive
Director, Hospice of the Rock River Valley, 815 288-3673.
-
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 Executive Director, Hospice of the Rock River Valley, 815
288-3673. 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 Executive Director, Hospice of the
Rock River Valley, 815 288-3673. 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 Executive Director, Hospice of the Rock River Valley,
815 288-3673. 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 Executive Director, Hospice of the
Rock River Valley, 815 288-3673. 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 Executive
Director, Hospice of the Rock River Valley, 815 288-3673 or obtain a copy
from our website at www.HospiceRockRiver.Org.
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 the Executive
Director, Hospice of the Rock River Valley, 815 288-3673. 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 Executive
Director as its contact person for all issues regarding patient privacy and
your rights under the Federal privacy standards. You may contact this
person at 815 288-3673.
COMPLAINTS
If you believe your privacy rights have been violated,
you may file a complaint with Hospice of The Rock River Valley or with the
Secretary of the Department of Health and Human Services. To file a
complaint with the hospice, contact the Executive Director. All complaints
must be submitted in writing with a description of the persons and acts or
omissions that are the subject of the complaint. YOU WILL NOT BE PENALIZED
FOR FILING A COMPLAINT.
ACKNOWLEDGEMENT OF RECEIPT
Your written acknowledgement of having received this
privacy practice notice is needed.
Please sign and date the Notice of Receipt of the
Privacy Practices on the first date of service or as soon as possible.
Thank you.
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE
CONTACT the Executive Director, Hospice of the Rock River Valley, 815
288-3673.
|