Notice of Privacy Practices Effective June, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

We understand that your medical information and information about your health is personal. We are committed to maintaining the privacy of your protected health information (“PHI”), which includes your medical and/or mental health condition and the care and treatment you receive from us. We create and maintain a record of the care and services you receive here. We use this record to provide you with quality care and to comply with certain legal requirements.

Our Responsibilities

We are required by law to maintain the privacy of your protected health (“PHI”) and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our legal duties and practices with respect to your PHI. We are required to abide by the terms of this Notice as are currently in effect.

How We May Use and Disclose Your PHI

The following categories describe different ways we may use and/or share your PHI without a written authorization from you. For each category, an explanation of the category is provided, in some cases with examples. These examples are not meant to include all possible types of use and/or disclosure. However, all of the ways we are permitted to use and disclose your PHI will fall into one of these categories.

Treatment. We may use and disclose your PHI to coordinate care within our organization and with others involved in your care, such as your attending physician, members of our interdisciplinary team and other health care professionals who have agreed to assist us in coordinating care. For example, we may disclose your PHI to a physician involved in your care who needs information about your symptoms to prescribe appropriate medications. We also may disclose your PHI to individuals outside of our organization who are involved in your care, including family members, other relatives, close personal friends, pharmacists, suppliers of medical equipment or other health care professionals.

Payment. We may use and disclose your PHI to receive payment for the care you receive from us. For example, we may be required by your health insurer to provide information regarding your health care status, your need for care and the care that we intend to provide to you so that the insurer will reimburse you or us.

Health Care Operations. We may use and disclose PHI for our own operations. These uses and disclosures are necessary for hospice services and to make sure that all of our patients receive quality care. For example, we may use your PHI for quality assessment and performance improvement activities, performance evaluations of our employees, training of student interns, business planning and development, business management activities, credentialing/licensure, surveys and conducting or arranging other business activities.

Facility Directory. We may disclose certain information about you, including your name, your general health status, your religious affiliation and where you are in our facility, in our patient directory. We may disclose this information to people who ask for you by name. Please inform us if you do not want your information to be included in the directory.

Fundraising Activities. We may use information about you, including your name, address, telephone number and the dates you received care, in order to contact you to raise money for our organization. If you do not wish to be contacted for fundraising activities, notify the Marketing Project Coordinator at (678) 328-1700 / (855) 328-1700 and indicate that you do not wish to be contacted.

Appointment Reminders. We may use and disclose your PHI to contact you to provide appointment reminders.

Treatment Alternatives/Benefits. We may use and disclose your PHI to tell you about or recommend possible treatment alternatives, or other health-related benefits or services that may be of interest to you.

Required by Law. We will disclose your PHI when it is required to do so by any federal, state or local law.

Public Health Activities. We may disclose your PHI for public activities and purposes in order to:

  • Prevent or control disease, injury or disability.
  • Report births or deaths.
  • Report the abuse or neglect of a child or dependent adult.
  • Report reactions to medications or problems with products.
  • Notify individuals exposed to a disease who may be at risk for contracting or spreading the disease.

Abuse, Neglect or Domestic Violence. We are 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.

Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. However, we may not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.

Judicial and Administrative Proceedings. We may disclose your PHI 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 we make reasonable efforts to either notify you about the request or to obtain an order protecting your PHI.

Law Enforcement. As permitted or required by State law, we may disclose your PHI to a law enforcement official for law enforcement/emergency purposes, which include, but are not limited to:

  • 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.
  • 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 we have a suspicion that your death was the result of criminal conduct, including criminal conduct at our facility.
  • In an emergency in order to report a crime.

Coroners, Medical Examiners, Funeral Directors. We may disclose your PHI to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law. We may also disclose your PHI to funeral directors if necessary to carry out their duties.

Organ, Eye or Tissue Donation. We may use or disclose your PHI 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.

Research Purposes. We may, under certain circumstances, use and disclose your PHI for research purposes. All research projects which use your PHI are subject to a special approval process which will, among other things, evaluate the precautions used to protect patient medical information. In many cases, information which identifies you as the patient will be removed.

Limited Data Set. We may use or disclose a limited data set of your PHI, that is, a subset of your PHI for which all identifying information has been removed, for purposes of research, public health, or health care operations. Prior to our release, any recipient of that limited data set must agree to appropriately safeguard your PHI.

Serious Threat to Health or Safety. We may, consistent with applicable law and ethical standards of conduct, disclose you PHI if we, in good faith, believe 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.

Specified Government Functions. In certain circumstances, the Federal regulations authorize us to use or disclose your PHI 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.

Worker’s Compensation. We may release your PHI for worker’s compensation or similar programs.

Authorization

Uses and/or disclosures of PHI, other than those described above, will be made only with your written authorization. You may cancel the authorization, at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights Regarding Your PHI

You have the following rights regarding your PHI.

1. Right to Request Restrictions/Disclosures – You have the right to request restrictions on certain uses and disclosures of your PHI. However, we are not required to agree to a requested restriction. If you wish to make a request for restrictions, please submit your written request to the Administrator at the Halcyon Hospice Office. The following information will NOT be disclosed without your authorization:

  • Psychotherapy notes and/or other types of PHI related to such therapy.
  • Use of your PHI for the company’s marketing purposes, including subsidized treatment communications.
  • Any disclosures that constitute a sale of your PHI.
  • Any other uses or disclosures not already described in this Notice.

2. Right to Receive Confidential Communications – You have the right to request that communications of your PHI are done by alternative means or at alternative locations. If you wish to receive confidential communications, please submit your written request to the Administrator at 1435 Haw Creek Circle East, Suite 402, Cumming, GA 30041.

3. Right to Inspect and Obtain a Copy of Your PHI – You have the right to inspect and obtain a copy of your PHI, as provided by law. If you wish to inspect and obtain a copy of your PHI, please submit your written request to the Administrator at (678) 328-1700 or by mail to 1435 Haw Creek Circle East, Suite 402, Cumming, GA 30041. We may charge you a fee for the cost of copying, mailing or other supplies associated with completing your request.

4. Right to Amend – You have the right to amend your PHI, as provided by law. To request an amendment, you must submit a written request including a reason that supports your request to the Administrator at 1435 Haw Creek Circle East, Suite 402, Cumming, GA 30041. We may deny your request to amend if:

  • It is not in writing;
  • You do not include a reason for the amendment;
  • The information you wish to amend was not created by us (unless the individual or entity that created the information is no longer available);
  • The information is not part of your PHI maintained by us;
  • The information is not part of the PHI you would be permitted to inspect and copy; and/or
  • The information is accurate and complete.

If you disagree with our denial, you have the right to submit a written statement of disagreement to us. We may prepare a response to your statement and will provide you with a copy.

5. Right to Receive an Accounting – You have the right to receive an accounting of who your PHI has been shared with, what was shared and when it was shared. This right applies to those purposes other than treatment, payment or health care operations, as previously described.

6. Right to Receive a Paper Copy of this Notice – You have the right to receive a paper copy of this Notice at any time. To obtain a copy, please request it from the Patient Care Manager.

7. Right to Receive Notification of Breach of unsecured PHI – You have the right (and we are required) to notify you in the event that there is any breach of your PHI by unauthorized persons/entities.

8. Right to Refuse to Disclose PHI to your Health Plan – If you have paid for your healthcare services out of your own pocket, you have the right to request that Halcyon Hospice not disclose your PHI related to those services that you paid for to your health plan. We will honor that request except where we are required by law to make such a disclosure

9. Right to Have Genetic PHI Kept Private – Halcyon Hospice is prohibited from using or disclosing any of your genetic PHI/information for underwriting purposes, except with limited exceptions for certain issuers of long-term care insurance policies.

Changes to this Notice

We reserve the right to change the terms of this notice and to make the revised notice provisions effective for all health information we already have about you, as well as any information we may receive in the future. We will post a copy of the current Notice in a clear and prominent location on our website at: www.excellencein hospice.com. A copy of the Notice is also available to you upon request. If the Hospice revises the Notice, the Hospice will inform you that revisions to the Notice have been made and will inform you of how you can review the revised Notice or request a copy of the revised Notice which will then be sent to you.

Questions Regarding this Notice

If you have any questions or need further information regarding this Notice, you may contact the Administrator at (678) 328-1700.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact the Compliance Officer at (678) 328-1700 (or through our toll-free Compliance Hotline at (855) 232-0646) or via email at: compliance@halcyonhealthcare.com. All complaints will be documented in writing. You will not be retaliated against in any way for filing a complaint.