Hospice of the Comforter -  Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT OUR PATIENTS MAY BE USED AND DISCLOSED AND HOW PATIENTS CAN GET ACCESS TO THIS INFORMATION. THE EFFECTIVE DATE IS APRIL 14, 2003. PLEASE REVIEW IT CAREFULLY.

USE AND DISCLOSURE OF HEALTH INFORMATION
Hospice of the Comforter (HOTC) may use patient health information that constitutes protected health information (PHI) as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Information Portability and Accountability Act (HIPAA) of 1996 for purposes of providing treatment, obtaining payment for patient care and conducting health care operations. HOTC has established a policy to guard against unnecessary disclosure of health information and complies with all State and Federal laws regarding PHI.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. HOTC may use health information to coordinate care within the Hospice and with others involved in patient care, such as the attending physician, members of our interdisciplinary team and other health care professionals who have agreed to assist HOTC in coordinating care. For example, physicians involved in patient care will need information about symptoms in order to prescribe appropriate medications. We also may disclose appropriate health care information to individuals outside of HOTC involved in patient care including family members, designated clergy, pharmacists, suppliers of medical equipment or other health care professionals that HOTC uses in order to coordinate patient care.

To Obtain Payment. HOTC may include health information in invoices to collect payment from third parties for the care received from HOTC. For example, HOTC may be required by a health insurer to provide information regarding patient’s health care status so that the insurer will reimburse the patient or HOTC. HOTC also may need to obtain prior approval from insurers and may need to explain to the insurer the need for Hospice care and the services provided to the patient.

To Conduct Health Care Operations. HOTC may use and disclose health care information for internal operations in order to facilitate the function of HOTC and as necessary to provide quality care to all patients. Health care operations include 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-healthcare professionals.

• Accreditation, certification, licensing or credentialing activities.

• Emergency management officials, transport and law enforcement services, and electric power suppliers in cases involving supplying those appropriate services involved in the patient’s care during an emergency situation.

• 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, HOTC may use patient information to evaluate its staff performance, combine health information with other Hospice patients in evaluating how to more effectively serve all HOTC patients, disclose health information to HOTC staff and contracted personnel for training purposes, use health information to contact patients as a reminder regarding a visit, or contact patients or their family as part of general fundraising and community information mailings unless they do not want to be contacted. If patients wish to opt out, they must notify the Director of Compliance and Quality at (407) 682-0808, (ext. 624).

For Inpatient Directory. HOTC may disclose certain information about our patients including name, general health status, religious affiliation and the location of patient in our facility or in our patient directory while in our inpatient facility. HOTC may disclose this information to people who ask for the patient by name. Patients should inform HOTC if they do not want information to be included in the directory.
Memorial Donations. HOTC may verbally verify patient name and care dates to those wishing to make memorial donations.

For Memorial Services Newsletters. If, at the time of a family memorial service, the family chooses to have the patient’s name read, that will be done. Patient's names with memorial donors may be published in our newsletters unless patients opt out by contacting the Director of Compliance and Quality at 407-682-0808 (ext. 624).Hospice of the Comforter

For Fundraising Activities. HOTC may use information including patient name, address, phone number and the dates care was received at Hospice in order to contact patients to raise money for HOTC. We may also release this information to a related Hospice foundation. If patients do not want these contacts, they must notify the Director of Compliance and Quality at 407-682-0808 (ext. 624) and indicate that they do not wish to be contacted.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH THE FEDERAL PRIVACY RULES ALLOW HOTC TO USE OR DISCLOSE PATIENT HEALTH INFORMATION WITHOUT CONSENT OR AUTHORIZATION:

For Appointment Reminders. HOTC may use and disclose health information to contact patients as a reminder that they have an appointment for a home visit.

For Treatment Alternatives. HOTC may use and disclose health information to tell patients about or recommend possible treatment options or alternatives that may be of interest to them.

When Legally Required. HOTC will disclose health information when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health. HOTC may disclose 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.

• To 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.

• To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

• To notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect or Domestic Violence. HOTC is allowed to notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We 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. HOTC may disclose health information to a health oversight agency for activities including audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary action. However, we may not disclose health information if the patient is the subject of an investigation and the health information is not directly related to the receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings. HOTC may disclose 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, in response to a subpoena, discovery request or other lawful process. This may occur only when HOTC makes reasonable efforts to either notify our patients about the request or to obtain an order protecting health information.

• For Law Enforcement Purposes. As permitted or required by state law, HOTC may disclose health information to a law enforcement official for 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, summons or similar process.

• For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.

• Under certain limited circumstances, when the patient is the victim of a crime.

• To a law enforcement official if we have a suspicion that the patient’s death was the result of criminal conduct including criminal conduct at HOTC.

• In an emergency in order to report a crime.

To Coroners and Medical Examiners. HOTC may disclose patient health information to coroners and medical examiners for purposes of determining cause of death or for other duties, as authorized by law.

To Funeral Directors. HOTC may disclose patient health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to funeral arrangements. If necessary to carry out their duties, HOTC may disclose health information prior to and in reasonable anticipation of the patient’s death.

For Organ, Eye Or Tissue Donation. HOTC may use or disclose 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. HOTC may, under very select circumstances, use patient’s health information for research. Before we disclose any health information for such research purposes, the project will be subject to an extensive approval process. We will ask permission before any researcher will be granted access to individually identifiable health information.

In The Event Of A Serious Threat to Health or Safety. HOTC may, consistent with applicable law and ethical standards of conduct, disclose health information if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the patient’s health or safety or to the health and safety of the public.

For Specific Government Functions. In certain circumstances, the Federal regulations authorize HOTC to use or disclose 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. HOTC may release patient health information for worker’s compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, HOTC will not disclose patient health information without a written authorization. The authorization may be revoked in writing at any time by the patient or the patient’s legal representative.Hospice of the Comforter

PATIENT RIGHTS WITH RESPECT TO THEIR HEALTH INFORMATION
The patient has the following rights regarding health information that HOTC maintains:
The right to request restrictions. Restrictions may be requested on certain uses and disclosures of health information. The patient has the right to request a limit on disclosure of health information to someone who is involved in the care or the payment of the care. However, HOTC is not required to agree to the request. All requests for restrictions must be made in writing to the Director of Compliance and Quality (see, "contact person" address).

The right to receive confidential communications. Patients have the right to request that HOTC communicate with them in a certain way. For example, patients may ask that HOTC only conduct communications pertaining to health information privately with no other family members present. If patients wish to receive confidential communications, they should contact the Director of Compliance and Quality at 407-682-0808, ext. 624. HOTC will not require that the patient provide any reasons for the request and will attempt to honor all reasonable requests for confidential communications.

The right to inspect and copy health information. Patients have the right to inspect and copy their health information, including billing records. A request to inspect and copy records containing health information must be made in writing to the Director of Compliance (see “contact person” address). If a patient requests a copy of their health information, we may charge a reasonable fee for copying and assembling costs associated with such request.

The right to amend health care information. If the patient or the patient’s legal representative believes that the patient’s health information records are incorrect or incomplete, a request may be made that HOTC amend the records. That request may be made as long as the information is maintained by HOTC. A request for an amendment of records must be made in writing to the Director of Compliance and Quality (see “contact person” address). HOTC 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 the health information records were not created by HOTC, if the records requested are not part of HOTC records, if the health information to be amended is not part of the health information the patient or patient’s legal representative are permitted to inspect and copy, or if, in the opinion of HOTC, the records containing health information are accurate and complete.

The right to an accounting. The patient or patient’s legal representative has the right to request an accounting of disclosures of health information made by HOTC for certain reasons, including reasons related to public purposes authorized by law and certain research. The types of disclosures excluded from the accounting provided include: disclosures pursuant to an authorization; that are incidental to another permissible use or disclosure; that are part of a limited data set, made for the purposes of treatment, payment or other health care operations; including those made to business associates; made to the individual who is the subject of the information; made for the purpose of inclusion in a facility directory or to persons involved in the individual’s care or other notification purposes; made for national security or intelligence purposes; made to correctional institutions or law enforcement officials; and made prior to April 14, 2003 (the compliance date of the Privacy Rules). The request for an accounting must be made in writing to the Director of Compliance and Quality (see, "contact person" address). 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 years. HOTC will provide the first accounting request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

The right to a paper copy of this notice. The patient or the patient’s legal representative has a right to a separate paper copy of this notice at any time, even if this notice has been previously received. To obtain a separate paper copy, please contact the Director of Compliance and Quality at 407-682-0808, (ext. 624), or a copy of the current version of HOTC Notice of Privacy Practices may be obtained at www.hospiceofthecomforter.org.

DUTIES OF THE HOSPICE
HOTC is required by law to maintain the privacy of health information and to provide to our patient and/or the patient’s legal representative this notice of our duties and privacy practices. We are required to abide by terms of this notice as may be amended from time to time. We reserve the right to change the terms of our notice and to make the new notice provisions effective for all health information that it maintains. If we change this notice, we will provide the current version on the HOTC website at www.hospiceofthecomforter.org and provide a paper copy upon request of the contact person below. The patient, caregiver or legal representative has the right to express complaints to HOTC and to the Secretary of Health and Human Services if it is believed that the patient’s privacy rights have been violated. Any complaints to HOTC should be made in writing to the Director of Compliance and Quality (see, "contact person" address). We encourage patients to express any concerns regarding the privacy of their information. There will not be retaliation for filing a complaint.

CONTACT PERSON
Hospice of the Comforter's contact person for all issues regarding patient privacy and rights under the Federal and State privacy standards is the Hospice Privacy Official—the Director of Compliance and Quality, 480 W. Central Parkway, Altamonte Springs, Florida, 32714. Telephone: 407-682-0808, ext. 624.

IF PATIENTS HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT HOTC.