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!
I. USE AND DISCLOSURE OF HEALTH INFORMATION
Roze Room Hospice [“Hospice”] may use your health information (information that 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) for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Hospice 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 THE LAW PERMITS YOUR HEALTH INFORMATION TO BE USED AND DISCLOSED:
To Provide Treatment. The Hospice may use your health information to coordinate care within the Hospice 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 Hospice in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. The Hospice also may disclose your health care information to individuals outside of the Hospice involved in your care including family members, caregivers, clergy who you have designated, pharmacists, suppliers of medical equipment or other health care professionals.
To Obtain Payment. The Hospice may use and disclose your health information to collect payment from third parties for the care you receive from the Hospice. For example, the Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Hospice. For this purpose, your health information may be used and disclosed on invoices, correspondence and other communications with your health insurer. The Hospice also may need to obtain prior approval from your insurer and may need to use and disclose health information to explain to the insurer your need for hospice care and the services that will be provided to you.
To Conduct Health Care Operations. The Hospice may use and disclose health information for its own operations in order to facilitate the function of the Hospice and as necessary to provide quality care to all of its 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, volunteers, trainees or practitioners in health care learn under supervision.
Training of non-health care professionals.
Accreditation, certification, licensing or credentialing activities (including, but not limited to activities of the Joint Commission and California Department of Health Services.)
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 the Hospice 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 as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).
For Fundraising Activities. The Hospice may use information about you including your name, address, phone number and the dates you received care in order to contact you or your family to raise money for the Hospice. The Hospice may also release this information to a related or affiliated Hospice foundation. If you do not want the Hospice to contact you or your family for this purpose, notify Roze Room Hospice Privacy Officer at Roze Room Hospice,
5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: email@example.com, and indicate that you do not wish to be contacted for this purpose.
For Appointment Reminders. The Hospice may use and disclose your health information to contact you as a reminder that you have an appointment for a visit.
For Treatment Alternatives. The Hospice 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 WITHOUT YOUR PRIOR AUTHORIZATION OR CONSENT, UNLESS SUCH DISCLOSURE IS FURTHER RESTRICTED OR LIMITED BY CALIFORNIA LAW:
When Legally Required. The Hospice 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. The Hospice 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.
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 allowed to notify government authorities if the Hospice believes a patient is the victim of abuse, neglect or domestic violence. The 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. The Hospice may disclose your health information to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The 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. 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 a subpoena, discovery request or other lawful process, but only when the Hospice makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by State law, the Hospice may disclose your health information to a law enforcement official for certain 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 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 purposes 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.
For Organ, Eye Or Tissue Donation. The Hospice 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. The Hospice 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.
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.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize the Hospice 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. The Hospice may release your health information for worker's compensation or similar programs.
THE FOLLOWING IS A SUMMARY STATEMENT OF CIRCUMSTANCES UNDER WHICH YOUR AUTHORIZATION IS NEEDED TO USE OR DISCLOSE HEALTH INFORMATION:
Except as described and stated above, the Hospice will not disclose your health information other than with your written authorization. For example, we will not share your information for marketing purposes or sell you information, unless you give us written permission. 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.
II. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Hospice 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 the Hospice ‘s disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: firstname.lastname@example.org.
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 the 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 Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: email@example.com. The 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 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 Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: firstname.lastname@example.org. If you request a copy of your health information, the Hospice may charge a reasonable fee for copying and assembling costs associated with your request. You can request a copy of your records to be provided in paper or electronic format, or both, depending on how Hospice generates and stores your records.
Right to amend health care information. You or your representative have the right to request that the Hospice amend your records, whether paper or electronic, 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 Hospice. A request for an amendment of records must be made in writing to Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: email@example.com. The Hospice 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 Hospice, if the records you are requesting are not part of the Hospice‘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 Hospice, the records containing your health information are accurate and complete. We will advise you within 60 days if your request is denied.
Right to an accounting. You or your 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. The request for an accounting must be made in writing to Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: firstname.lastname@example.org. 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. The Hospice 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. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
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 received this Notice previously. To obtain a separate paper copy, please contact Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: email@example.com. The patient or a patient’s representative may also obtain a copy of the current version of the Hospice’s Notice of Privacy Practices at its website, www.rozeroomhospice.org.
Right to choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will need to be provided with information to confirm that this person has authority and can act on your behalf.
Right to instruct us how to use your information. For certain health information, you can inform Hospice of your choices about what information Hospice may share. If you have a clear preference for how Hospice should share you information in the situations below, please inform Hospice so Hospice can follow your instructions. These situations include, Hospice sharing information with your family, close friends or others involved in your care; sharing information in a disaster relief situation; and inclusion of your information in patient directory. If you are not able to tell Hospice your preference, for example, if you are unconscious, Hospice may share your information, if Hospice believes it is in your best interest. Hospice may also share your information when needed to lessen a serious and imminent threat to health or safety.
III. DUTIES OF THE HOSPICE
The Hospice 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. Hospice will notify you if a breach occurs that may have compromised the privacy or security of your protected information. Hospice is required to abide by the terms of this Notice as may be amended from time to time. Hospice 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 Hospice changes its Notice, the Hospice 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 Hospice and to DHHS if you or your representative believe that your privacy rights have been violated. Any complaints or concerns regarding the privacy of your information should be made in writing to Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: firstname.lastname@example.org. You can file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights by sending a letter to 200 Independence Avenue, S.W. Washington, D.C. 20201, (877) 696-6775, www.hhs.gov/ocr/privacy/hipaa/complaints/. Hospice will not retaliate against you for filing a complaint.
IV. CONTACT PERSON
The Hospice has designated a Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact the Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: email@example.com.
V. EFFECTIVE DATE
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT: Roze Room Hospice Privacy Officer at Roze Room Hospice, 5000 Overland Ave, Suite 101, Culver City, CA 90230, (310) 202-7693, email: firstname.lastname@example.org.