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.

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

OUR RESPONSIBILITIES

Hospice Promise, LLC takes the privacy of your health information seriously. We are required by law to maintain that privacy and provide you with this Notice of Privacy Practices (herein referred to as “Notice”). This Notice is provided to tell you about our practices with respect to your information. Hospice Promise, LLC is required to abide by the term of this Notice as are currently in effect and to notify you in the event of a breach of your health information.
We are required by law to:

• Maintain the privacy of your Protected Health Information;
• Provide you with this Notice of our legal duties and privacy practices related to your Protected Health Information; and
• Abide by the terms of this Notice that are currently in effect

 

HOW HOSPICE PROMISE, LLC MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

You will be asked to sign a consent allowing us to use and disclose your Protected Health Information to others to provide you with treatment, obtain payment for services and run our health care operations. The following in each category is listed. However, all of the ways that your information is used falls into one of these categories.

To Provide Treatment: Hospice Promise. LLC may use and disclose your health information to coordinate care within Hospice and with others involved in your care. For example, the hospice interdisciplinary team and physicians involved in your care will need information about your history, symptoms, disease and prognosis in order to coordinate care. Other health care professionals may include (but are not limited to) community physicians; pharmacists; suppliers of medical equipment, laboratory and radiology services; and clergy. Family and caregivers will be utilized in the coordination of care, unless specifically excluded by you.

To Obtain Payment: Hospice Promise, LLC may use and disclose your health information to receive payment for the care you receive. For example, Hospice Promise. LLC (herein referred to as “the Hospice”) may be required by your health insurer to provide information regarding your health care status so that the insurer will authorize services or reimburse you or the Hospice.

To Conduct Health Care Operations: Hospice Promise, LLC may use and disclose health information for its own operations to facilitate the functioning of the Hospice and as necessary to provide quality care to all Hospice patients. For example, the Hospice may use your health information to evaluate its performance, combine your health information with other Hospice patients in evaluating how to more effectively service all Hospice patients, disclose your health information to members of the Hospice workforce for training purposes, use your health information to contact you as a reminder for visitation, or contact you as part of general fundraising and community informational mailings (unless you tell us you do not want to be contacted).
Health care operations may include such activities as:

• Quality assessment and improvement activities;
• Coordination of benefits with Division of Family Services, Division of Aging, Social Security, the Department of Veteran Affairs, State Veteran’s Commissions and other agencies;
• Activities designed to improve health care 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 analysis and formulary development; and
• Business management and general administrative activities of the hospice.

 

FEDERAL PRIVACY RULES ALLOW THE HOSPICE TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR OTHER SPECIFIC PURPOSES

When Legally Required: The Hospice will disclose your health information when it is required to do so by any federal, state, or local law.

Business Associates: Protected Health Information may be shared with our vendors and agents who create, receive, maintain, or transmit Protected Health Information for certain functions or activities on behalf of Hospice Promise. These are called “Business Associates” and include any subcontractor that creates, receives, Maintains or transmits Protected Health Information to a billing company to assist us with billing, or to a law firm that assists us in complying with the law. To protect and safeguard your health information, Hospice Promise, LLC requires all Business Associates and subcontractors to appropriately safeguard your information.

Family and Friends Involved in Your Care: Unless you object, Protected Health Information may be disclosed to a family member or close personal friend, including clergy, who is involved in your care or payment for that care. You may ask us any time not to disclose your health information to any person(s) involved in your care. We will agree to your request unless circumstances constitute an emergency or if the patient is a minor.

Personal Representative: If you have a personal representative, such as a legal guardian, that person will be treated as if that person is you with respect to disclosures of your Protected Health Information. If you become deceased, your health information may be disclosed to an executor or administrator of your estate, to the extent that person is acting as your personal representative or next of kin, as permitted under state and federal law.
When there are Risks to Public Health: The Hospice may disclose your health information for public activities and purposes to:

• Prevent or control disease, injury, or disability; report disease, injury, vital events such as birth or death and to conduct public health surveillance, investigations and interventions;
• Report adverse events or product defects; to track products or enable products recalls, repair and replacements; and to comply with requirements of the Food and Drug Administration;
• 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 mandated to notify government authorities if it believes a patient is a victim of abuse, neglect, or domestic violence.

To Conduct Health Oversight Activities: The Hospice may disclose your health information to a health oversight agency authorized by law for activities including audits, civil administrative agencies that oversee the health care system, government benefit programs and other governmental regulatory programs and civil rights laws. The Hospice, however, may not disclose your health information if you are 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 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 effects to either notify you about the request or to obtain an order protecting your health information.

For Law Enforced Purposes:

• As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court, warrant, subpoena summons or similar process.
• For the purpose od 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 the purpose 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.
The Hospice may use or disclose your health information to organ procurement organization or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation, if you so desire.

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.

Disaster Relief: The Hospice may disclose your Protected Health Information to an organization assisting in disaster relief efforts.

For Specific Government Functions: In certain circumstances, Federal regulations authorize the Hospice to use or disclose your health information to facilitate specified government functions related to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates in law enforcement custody.

For Workers’ Compensation: The Hospice may release your health information for workers’ compensation or similar programs.

Research: The Hospice may, under certain circumstances, use and disclose your health information for research purposes. In general, we will request that you sign a written authorization before using your Protected Health Information or disclosing it for research purposes, the project will be subject to an extensive approval process. Health information may be used without your written authorization for research purposes provided that the research has been reviewed and approved by an Institutional Review Board.

Limited Data Set: The Hospice may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health and health care operations. Prior to our release, any recipient of that limited data set must agree to appropriately safeguard your health information.

De-identified Information: The Hospice may use your Protected Health Information to create ‘de-identified’ information or we may disclose your information to a Business Associate so that the Business Associates can create de-identified information on our behalf. De-identification removes any health information that identified information on our behalf. De-identification removes any health information that identifies you as the source for that 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. IF YOU REVOKE YOUR AUTHORIZATION. THE HOSPICE WILL NO LONGER USE OR DISCLOSE HEALTH INFORMATION ABOUT YOU FOR THE REASONS COVERED IN YOUR WRITTEN AUTHORIZATION. YOU UNDERSTAND THAT THE HOSPICE IS UNABLE TO TAKE BACK ANY DISCLOSURES IT HAS ALREADY MADE UNDER THE AUTHORIZATION.
OTHER USES OR DISCLOSURES OF HEALTH INFORMATION

Except as otherwise permitted or required by this Notice of Privacy Practices, the Hospice will not use or disclose your health information unless you provide written authorization. Written authorization is required for the following:

• Uses and disclosures for marketing purposes;
• Uses and disclosures for fundraising
• Uses and disclosures that constitute a sale of health information; and
• Any other uses and disclosures not describe in this Notice.

 

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

The right to request restrictions on certain uses and disclosures of your health information: You have the right to request restrictions on the Hospice’s disclosure of your health information for treatment, payment or health care operations. You also have the right to request restrictions on the way we disclose your Protected Health Information to a family member, friend or other person(s) involved in your care. The Hospice is not required to agree to your request, unless your request is for a restriction on a disclosure to a health plan for purposes of payment or health care operations (and it not for purposes of treatment) and the medical information you are requesting to be restricted from disclosure pertains solely to a health care item or services for which you have paid out of pocket in full. If you wish to make a request for restrictions, please contact the Hospice Administrator.

The 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 Hospice conduct communications privately with you with no other family member present. If you wish to receive confidential communication, please contact the Hospice Administrator. The Hospice Will not request that you provide reasons for your request and will attempt to honor your reasonable request for confidential communications.

The right to inspect and copy your health information: You have the right to inspect and copy your health information, including billing records. A request in writing to inspect and copy records containing your health information may be made to the Hospice Administrator. We will allow you to inspect your records within 10 days of your request. If you request copies of the records, we will provide you with copies within a reasonable time frame, but no more than 3o days if the records are maintained on site and 6o days if the records are maintained off-site. The hospice may charge a reasonable fee for copying and assembling costs associated with your request. You also have the right to request that Hospice provide you, an entity or a designated individual with an electronic copy of your electronic health record containing your health information. The Hospice may require you to pay the labor costs incurred by the Hospice in responding to your request.

The right to amend health care information: You or your representative has the right to request that the Hospice amend your records if your health information is incorrect or incomplete. A request for an amendment of records must be made in writing to the Hospice Administrator and include the reason for the requested amendment. The request may also be denied if your health information records wee 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 are 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.

The right to an accounting of disclosures: You or your health 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. This accounting does not include disclosures made for treatment, payment and health care operations.

The request for an accounting must be made in writing to:

Executive Director
Hospice Promise, LLC
12213 W. Bell Road, Suite 115, Surprise, AZ 85378
3100 W. Ray Road, Suite 201, Chandler, AZ 85226
623- 209-7003

The right to opt out of fundraising: You or your representative has the right to opt out of receiving fundraising communications.

The right to receive notification of a breach: You or your representative has the right to receive notification of the breach of your unsecured health information. Hospice Promises, LLC will notify you by first class mail or email if any breaches of unsecured health information occurred. You will be notified as soon as possible, but in any event, no later than 60 days following the breach. A “breach” means the unauthorized access, acquisition, use disclosure of Protected Health Information which comprises the security and privacy of Protected Health Information. If you have questions regarding what constitutes a breach or your rights with respect to breach notification, please contact the Executive Director at (623) 209-7003.

The right to a paper copy of this notice even though you had previously received a copy: You or representative have the right to a separate paper copy of this Notice at any time. You may request a copy of this Notice at any time by calling Hospice Promise, LLC and requesting a copy be mailed to you. The patient or patient representative may also obtain a copy of the current version of Hospice Promise, LLC’s Notice of Privacy Practices on its websites: www.hospicepromise.com

To exercise any of the above rights, please contact the Executive Director.

 

CHANGES TO THIS NOTICE

The Hospice reserves the right to change this Notice. The Hospice reserves the right to make the revised or new Notice provisions effective for health information we already have about you, as well as any health information we may receive in the future. We will promptly review and distribute this Notice whenever there is a material change to the uses and disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice and will mail/hand deliver a copy of the revised Notice to you or your personal representative. We will post a copy of the current Notice in a clear and prominent location at the Hospice Promise, LLC office. The Notice is also available to you upon request. The Notice will contain, at the end of this document, the effective date. In addition, if the Hospice revises the Notice, the Hospice will offer you a copy of the current Notice in effect. You can obtain a copy of this notice electronically at www.hospicepromise.com or by contacting the Hospice Promise Administrator.

 

COMPLAINTS

HOSPICE Promise, LLC encourages you to express any concerns regarding the privacy of your information. If you believe your privacy rights have been violated, you may file a complaint in writing to Hospice Promise, LLC or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with Hospice Promise, LLC, or for more information regarding filing a complaint.

Hospice Promise, LLC has designated the Administrator as the Hospice ‘s Privacy Officer and its contact person for all issues regarding patient privacy, your rights and complaints under the Federal privacy standards.

HOSPICE CONTACT: Any complaints or concerns should be made in writing to:
Hospice Promise, LLC
12213 W. Bell Road, Suite 115, Surprise, AZ 85378
3100 W. Ray Road, Suite 201, Chandler, AZ 85226
(623)209-7003
or
Call the Arizona Department of Health Services hotline for complaints: (602) 364-3030 or 1-800-221-9968

OFFICE FOR CIVIL RIGHTS:
U.S. Department of Health and Human Services
200 Independence Avenue, S. W., Room 509F, HHH Building, Washington, D.C. 20201

EFFECTIVE DATE: This Notice is effective September 23, 2013