NOTICE OF HOSPICE OF THE PANHANDLE 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 of the Panhandle may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed only after Hospice has obtained your written consent. Hospice of the Panhandle has established a policy 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 AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT: To Provide Treatment Hospice of the Panhandle may use your health information to coordinate care within 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. Hospice of the Panhandle also may disclose your health care information to individuals outside of Hospice involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals that the Hospice uses in order to coordinate your care. To Obtain Payment Hospice of the Panhandle may include your health information in invoices to collect payment from third parties for the care you may 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. To Conduct Health Care Operations Hospice of the Panhandle may use and disclose health care 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 include 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, practitioners and non-health care professionals can learn under supervision 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 Hospice of the Panhandle. In reference to fundraising activities, Hospice of the Panhandle may use information about you including your name, address, phone number and the dates you received care at hospice in order to contact you or your family. If you do not want hospice to contact you or your family, notify the Privacy Officer and indicate that you do not wish to be contacted. For example, Hospice of the Panhandle 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 or your family as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted). Federal privacy rules allow Hospice of the Panhandle to use or disclose your health information without your consent or authorization for a number of reasons. When Legally Required Hospice of the Panhandle 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 of the Panhandle 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. Report to an employer about an individual who is a member of the workforce as legally required. To Report Abuse, Neglect Or Domestic Violence Hospice of the Panhandle is allowed to notify government authorities if the 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 of the Panhandle may disclose your health information to a health oversight agency 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 of the Panhandle 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 of the Panhandle makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information. For Law Enforcement Purposes Hospice of the Panhandle may disclose your 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 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 of the Panhandle 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 Hospice of the Panhandle 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 of the Panhandle 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 of the Panhandle 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 of the Panhandle 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. Hospice of the Panhandle will ask your permission if any researcher will be granted access to your individually identifiable health information. In the Event of A Serious Threat To Health Or Safety Hospice of the Panhandle 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 Hospice of the Panhandle 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 of the Panhandle 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 of the Panhandle will not disclose your health information without your written authorization. If you or your representative authorizes Hospice of the Panhandle 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 of the Panhandle 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 of the Panhandle is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Officer at Hospice of the Panhandle, 122 Waverly Court, Martinsburg, WV 25401. Telephone number is 304-264-0406 or 800-345-6538. Right to receive confidential communications You have the right to request that Hospice of the Panhandle 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 at Hospice of the Panhandle. 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 obtain a copy of your health information You have the right to inspect and obtain a copy of your health information, including billing records. A request to inspect and/or to obtain a copy of your records containing your health information may be made to the Privacy Officer at Hospice of the Panhandle at a cost of $10.00. Right to amend health care information If you or your representative believes that your health information records are incorrect or incomplete, you may request that Hospice of the Panhandle amend the records. 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 the Privacy Officer. Hospice of the Panhandle 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 of the Panhandle 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 has the right to request an accounting of disclosures of your health information made by Hospice of the Panhandle for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Privacy Officer. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. Hospice of the Panhandle 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 has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact the Privacy Officer at Hospice of the Panhandle. DUTIES OF HOSPICE OF THE PANHANDLE Hospice of the Panhandle is required by law to maintain the privacy of your health information and to provide you and your representative this Notice of its duties and privacy practices. Hospice of the Panhandle is required to abide by terms of this Notice as may be amended from time to time. Hospice of the Panhandle 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 notice is changed, Hospice of the Panhandle will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative has the right to express complaints to Hospice of the Panhandle and to the Secretary of Health and Human Services if you or your representative believes that your privacy rights have been violated. Hospice of the Panhandle 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 AT HOSPICE OF THE PANHANDLE The Hospice’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Officer, Hospice of the Panhandle, 122 Waverly Court, Martinsburg, WV 25403. The telephone number is 304-264-0406 or 800-345-6538. EFFECTIVE DATE This Notice is effective April 14, 2003.