Click Here To Download This Document (MS Word Format)
Hospice
of the Valley
Notice of 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 Valley (“Agency”) may use your health information
for purposes of providing you treatment, obtaining payment for your care and
conducting health care operations. Information 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.
The Agency 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:
1. To Provide Treatment. Hospice of the Valley may use your health information
to coordinate nate care within the Agency 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 Agency
in coordinating care. For example, physicians involved in your care will need
information about your symptoms in order to prescribe appropriate medications.
The Agency also may disclose your health care information to individuals outside
of the Agency involved in your care including family members, clergy, pharmacists,
suppliers of medical equipment or other health care professionals.
2. To Obtain Payment. Hospice of the Valley may include your health information
in invoices to collect payment from third parties for the care you receive
from the Agency. For example, Hospice of the Valley may be required by your
health insurer to provide information regarding your health care status so
that the insurer will reimburse you or the Agency. The Agency also may need
to obtain prior approval from your insurer and may need to explain to the
insurer your need for service and the services that will be provided to you.
3. To Conduct Health Care Operations. Hospice of the Valley may use and disclose
health information for its own operations in order to facilitate the function
of the Agency and as necessary to provide quality care to all of the Agency’s
patients. Health care operations include such activities as:
a. Quality assessment and improvement activities.
b. Activities designed to improve health or reduce health care costs.
c. Protocol development, case management and care coordination.
d. Contacting health care providers and patients with information about treatment
alternatives and other related functions that do not include treatment.
e. Professional review and performance evaluation.
f. Training programs including those in which students, trainees or practitioners
in health care learn under supervision.
g. Training of non-health care professionals.
h. Accreditation, certification, licensing or credentialing activities.
i. Review and auditing, including compliance reviews, medical reviews, legal
services and compliance programs.
j. Business planning and development including cost management and planning
related analyses and formulary development.
k. Business management and general administrative activities of the Agency.
l. Fundraising for the benefit of Hospice of the Valley.
For example, Hospice of the Valley 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 Agency patients,
disclose your health information to Agency 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).
If you have been a donor to Hospice of the Valley prior to your being a patient,
the Agency may use information about you including your name, address and
phone number to contact you to raise money for the Agency. If you do not want
the Agency to contact you, notify the Office Manager at 330-788-1992 and indicate
that you do not wish to be contacted.
4. For Appointment Reminders. Hospice of the Valley may use and disclose your
health information to contact you as a reminder that you have an appointment
for a home visit.
5. For Treatment Alternatives. Hospice of the Valley 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.
1. When Legally Required. Hospice of the Valley will disclose your health
information when it is required to do so by any Federal, State or local law.
2. When There are Risks to Public Health. Hospice of the Valley may disclose
your health information for public activities and purposes in order to:
a. 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.
b. 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.
c. Notify a person who has been exposed to a communicable disease or who may
be at risk of contracting or spreading a disease.
d. Notify an employer about an individual who is a member of the workforce
as legally required.
3. To Report Abuse, Neglect or Domestic Violence. Hospice of the Valley is
allowed to notify government authorities if the Agency believes a patient
is the victim of abuse, neglect or domestic violence.
4. To Conduct Health Oversight Activities. Hospice of the Valley may disclose
your health information to a health oversight agency for activities including
audits, civil administrative or criminal investigations, inspections, licensure
or disciplinary action. The Agency, 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.
5. In Connection with Judicial and Administrative Proceeding. Hospice of the
Valley may disclose your health information in the course of any judicial
or administrative proceeding in response to an order of a court of administrative
tribunal as expressly authorized by such order or in response to a subpoena,
discovery request or other lawful process, but only when the Agency makes
reasonable efforts to either notify you about the request or to obtain an
order protecting your health information.
6. For Law Enforcement Purposes. As permitted or required by State law, the
Agency may disclose your health information to a law enforcement official
for certain law enforcement purposes as follows:
a. 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.
b. For the purpose of identifying or locating a suspect, fugitive, material
witness or missing person.
c. Under certain limited circumstances, when you are the victim of a crime.
d. To a law enforcement official if the Agency has a suspicion that your death
was the result of criminal conduct including criminal conduct at the Agency.
e. In an emergency in order to report a crime.
7. To Coroners and Medical Examiners. Hospice of the Valley 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.
8. To Funeral Directors. Hospice of the Valley 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 Agency may disclose your health information prior
to and in reasonable anticipation of your death.
9. For Organ, Eye or Tissue Donation. Hospice of the Valley may use or disclose
your health information to organ procurement, banking or transplantation of
organs, eyes or tissue for the purpose of facilitating the donation and transplantation.
10. For Research Purposes. Hospice of the Valley may, under very select circumstances,
use your health information for research. Before the Agency discloses any
of your health information for such research purposes, the project will be
subject to an extensive approval process.
11. In the Event of a Serious Threat to Health or Safety. Hospice of the Valley
may, consistent with applicable law and ethical standards of conduct, disclose
your health information if the Agency, in good faith, believes that such disclosure
is necessary to prevent or lessen a serious and imminent threat or safety
or to the health and safety of the public.
12. For Specified Government Functions. In certain circumstances, the Federal
regulations authorize Hospice of the Valley to use or disclose your health
information to facilitate specified government functions relating to military
and veterans, national security and intelligence activities, protection services
for the President and others, medical suitability determinations and inmates
and law enforcement custody.
13. For Worker’s Compensation. Hospice of the Valley 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 Valley will not disclose your health
information other than with your written authorization. If you or your representative
authorizes the Agency 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 Agency
maintains:
1. 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 Agency’s disclosure of your health information to someone
who is involved in your care or the payment of your care. However, the Agency
is not required to agree to your request. If you wish to make a request for
restrictions, please contact the Medical Records Department at 330-788-1992.
2. Right to Receive Confidential Communications. You have the right to request
that Hospice of the Valley communicate with you in a certain way. For example,
you may ask that the Agency 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 your primary
nurse or the Clinical Supervisor at 330-788-1992. The Agency will not request
that you provide any reasons for your request and will attempt to honor your
reasonable requests for confidential communications.
3. 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 Medical Records Department at 330-788-1992. If you request a copy of
your health information, the Agency may charge a reasonable fee for copying
and assembling costs associated with your request.
4. Right to Amend Health Care Information. You or your representative have
the right to request that Hospice of the Valley 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 Agency. A request
for an amendment of records must be made in writing to the Medical Records
Department at 5190 Market Street, Youngstown, Ohio 44512. The Agency 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 Agency, if the records you are requesting are not part of the
Agency’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 Agency, the records containing
your health information are accurate and complete.
5. Right to an Accounting. You or your representative have the right to request
an accounting of disclosures of your health information made by Hospice of
the Valley 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 Medical Records Department at 5190 Market Street,
Youngstown, Ohio 44512. 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. Hospice of the Valley
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.
6. 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 receive this Notice previously. To obtain a separate paper
copy, please contact the Performance Improvement Director at 330-788-1992.
The patient or a patient’s representative may also obtain a copy of
the current version of the Agency’s Notice of Privacy Practices at its
website, www.hospiceofthevalley.com
DUTIES OF THE HOSPICE
Hospice of the Valley 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 Agency is required to abide by the terms
of this Notice as may be amended from time to time. Hospice of the Valley
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
Agency changes its Notice, Hospice of the Valley 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 Agency and to the
Secretary of DHHS if you or your representative believe that your privacy
rights have been violated. The Secretary of DHHS can be reached at 1-877-696-6775.
Any complaints to the Agency should be made in writing to the Performance
Improvement Director at 5190 Market Street, Youngstown, Ohio 44512. The Agency
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 complain.
CONTACT PERSON
Hospice of the Valley has designated the Performance Improvement Director as its contact person for all issues regarding patient privacy and your right under the Federal privacy standards. You may contact this person at 5190 Market Street, Youngstown, Ohio 44512 or 330-788-1992.
EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE PERFORMANCE IMPROVEMENT DIRECTOR, 5190 MARKET STREET, YOUNGSTOWN, OH 44512 OR 330-788-1992.