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.
If you have any questions about this Notice or complaints regarding your privacy, please contact the Inspiring Hospice Group Privacy Officer at 706-850-0900.
This notice of Privacy Practices as published on April 30, 2019 and replaces and previously issued Notice.
We are required by law to maintain the privacy of your personal health information and to provide you with notice of our legal duties and privacy practices related to your personal health information. This Notice of Privacy Practices describes how we may use and disclose your personal health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your personal health information. “Personal health information” is information, including demographic information (such as your age or your address), that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services or payment for such services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all personal health information that we maintain at that time. You may obtain a copy of any revised Notice of Privacy Practice by contacting the Privacy Officer.
Uses and Disclosures of Personal Health Information. Your personal health information may be used and disclosed by individuals that are involved in your care and treatment for the purpose of providing health care services to you. Your personal health information may also be used and disclosed to pay your health care bills and to support our operations. Other uses and disclosures may be made if you are given an opportunity to object to the use or disclosure or with your express authorization.
Examples of the types of permitted uses and disclosures of your protected health care information are explained below. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made. We will not provide a copy of your medical records to another person for any of the purposes described below without your express written consent except as explained in this Notice of Privacy Practices.
- Uses and Disclosures for Treatment, Payment and Practice Operations:
(1) Treatment: We may use and disclose your personal health information for our own treatment purposes or the treatment purposes of another health care provider. Treatment activities include the provision, coordination, or management of your health care and any related services. For example, we may disclose your personal health information, as necessary, to physicians who may be treating you.
(2) Payment: Your personal health information may be used or disclosed to obtain payment for the health care services we provide to you or for the payment purposes of another health care provider. For example, we may disclose your personal health information to your health plan to obtain approval for a hospital admission.
(3) Healthcare Operations: We may use or disclose your personal health information to support our business activities. These business activities include, but are not limited to, quality assessment activities, employee review activities, training, conducting or arranging for legal or consulting services, and business planning activities. We may also disclose your personal health information to another entity that is subject to the federal privacy protections to conduct certain business activities including quality assessments and improvement activities, reviews of the qualifications of health care professionals, evaluating provider performance or health care fraud and abuse detection or compliance. For example, we may disclose your personal health information to third party “business associates” that perform various activities for our organization such as billing services, our answering service and transcription services. Whenever an arrangement between our office and a business associate involves the use or disclosure of your personal health information, we will have a written contract that contains terms that are intended to protect the privacy of your personal health information. We may also use or disclose your personal health information to remind you of your appointments. In addition, we may use or disclose your personal health information to provide you with information about treatment alternatives or other health-related benefits and services that we offer that may be of interest to you. For example, your name and address may be used to send you a newsletter about our organization and the services we offer. We may also contact you to raise funds for the organization.
- Uses and Disclosures of Personal Health Information With Your Written Authorization: Uses and disclosures of your personal health information other than for treatment, payment or healthcare operations purposes will be made only with your written authorization, unless we are otherwise permitted or required by law to use or disclose your personal health information as described below. For example we will not use or disclose your personal health information for marketing purposes or sale without obtaining your authorization. If we have records for you that include psychotherapy notes, we will not disclose those notes without your authorization. You may revoke an authorization, at any time, in writing, except to the extent that we have already taken an action based on the use or disclosure permitted by the authorization.
- Permitted and Required Uses and Disclosures with an Opportunity to Object: We may use and disclose your personal health information in the instances described below. You will be given the opportunity, when possible, to agree or object to the use or disclosure of all or part of your personal health information. If you are not present or able to agree or object to the use or disclosure of the personal health information, then we may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the personal health information that is relevant to your health care will be disclosed.
- Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your personal health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on your physician’s professional judgment.
- Notification Purposes: We may use or disclose personal health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
- Disaster Relief: We may use or disclose your personal health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate with disaster relief agencies.
- Facility Directory: We may use and disclose your name, location, general condition, and religious affiliation for a patient directory for access by clergy and persons who specifically inquire about you by name, unless you object or otherwise restrict this use and disclosure. If you are incapacitated or an emergency treatment circumstance exists limiting your ability to object, some or all of the above information may be used in the patient directory if such use is not inconsistent with any of your prior expressed preferences, or it is believed by us to be in your best interests; in which case, when it becomes practicable to do so, we will provide you with the opportunity to object to the use described.
- Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or an Opportunity to Object: We may use or disclose your personal health information in the following situations without your authorization or without giving you an opportunity to object to the use or disclosure. These situations include:
- Required By Law: We may use or disclose your personal health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
- Public Health: We may disclose your personal health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure may be made for the purpose of controlling disease, injury or disability. For example, we may disclose your personal health information to public health authorities that are authorized by law to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. We may also disclose your personal health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
- Health Oversight: We may disclose personal health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
- Abuse or Neglect: We may disclose your personal health information to a public health authority that is authorized by law to receive reports of child or vulnerable abuse or neglect. In addition, we may disclose your personal health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws and you will be informed of the report except in certain limited circumstances.
- Food and Drug Administration: We may disclose your personal health information to a person or company required by the United States Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; enable product recalls; make repairs or replacements, or conduct post marketing surveillance.
- Legal Proceedings: We may disclose personal health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized) and in certain conditions in response to a subpoena, discovery request or other lawful process.
- Law Enforcement: We may also disclose personal health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises, and (6) in a medical emergency (not on our premises) when it is likely that a crime has occurred.
- Coroners, Funeral Directors, and Organ Donation: We may disclose personal health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose personal health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Personal health information may also be used and disclosed for cadaveric organ, eye or tissue donation purposes.
- Research: We may disclose your personal health information to researchers when their research has been approved by an institutional review board or appropriate privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your personal health information.
- Criminal Activity: Consistent with applicable federal and state laws, we may disclose your personal health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose personal health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
- Military Activity and National Security: When the appropriate conditions apply, we may use or disclose personal health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your personal health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
- Workers’ Compensation: Your personal health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
- Inmates: We may use or disclose your personal health information if you are an inmate of a correctional facility, your physician created or received your personal health information in the course of providing care to you and the disclosure of the information is necessary for your care, the health and safety of other inmates or correctional personnel or the administration of the correctional facility.
- Required Uses and Disclosures: We are required by law to make disclosures to you upon request. We are also required to make disclosures of your personal health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal privacy requirements.
- Use of Personal Health Information for Fundraising: We may contact you about fundraising activities for our organization; however, you have the right to opt out of receiving such fundraising communications from us at any time.
2. Your Rights
As a patient, you have certain rights related to your personal health information. The following information explains how you may exercise these rights.
- You have the right to inspect and copy your personal health information. This means you may inspect and obtain a copy of personal health information about you that is contained in a designated record set for as long as we maintain the personal health information. A “designated record set” contains medical and billing records and any other records that is used for making decisions about you. You must submit a written request to the Privacy Officer to inspect or copy your personal health information. We have the right to charge you a reasonable fee for a copy of your medical record. Under law, however, you may not inspect or copy the following records: (1) psychotherapy notes that are maintained separately from your medical record; (2) information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and (3) personal health information that is subject to law that prohibits access to personal health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact the Privacy Officer if you have questions about access to your medical record.
- You have the right to request a restriction of your personal health information. This means you may ask us not to use or disclose any part of your personal health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your personal health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, unless you request that we restrict disclosures to a health plan for payment or other healthcare operations purposes, the disclosure is not otherwise required by law, and the information pertains solely to a health care item or service you have fully paid for out of pocket. If we believe it is in your best interest to permit use and disclosure of your personal health information, your personal health information will not be restricted. If we agree to a restriction requested by you, we may not use or disclose your personal health information in violation of that restriction unless it is needed to provide emergency treatment. We may terminate our agreement to a restriction by providing you with written notice. Requests for restrictions must be submitted in writing to the Privacy Officer.
- You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests to receive confidential communications of your personal health information. We may condition this accommodation by asking you for information as to how payment will be handled or to specify an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to the Privacy Officer.
- You may have the right to amend your personal health information. This means you may request an amendment of personal health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a response to your statement and will provide you with a copy of our response. Please contact the Privacy Officer to determine if you have questions about amending your medical record.
- You have the right to receive an accounting of certain disclosures we have made, if any, of your personal health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we make after that are (1) pursuant to an authorization; (2) to you, (3) to family members or friends involved in your care, (4) incidental to other permitted disclosures, (5) for national security purposes, (6) for inmates to correctional institutions, (7) part of a limited data set that does not include any direct identifiers and that is subject to an agreement that protects the confidentiality of the personal health information, or (8) for notification purposes. You have the right to receive specific information regarding these disclosures for a period of up to six (6) years. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitation.
- You have the right to obtain a paper copy of this notice from us. Even if you have agreed to accept this notice electronically, we will furnish a copy of this Notice of Privacy Practices upon request. We will also notify you if there has been a breach of your personal health information in a way that would compromise the information.
- Complaints. You may submit a complaint to us if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Officer. We will not retaliate against you for filing a complaint. You may contact us about the complaint process. You also have the right to submit a complaint to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
Notice of Privacy Practices
Acknowledgement and Consent
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this form. By signing this form, you acknowledge receipt of this Notice of Privacy Practices. By signing this form, you also consent to Inspiring Hospice Group’s use and disclosure of your medical records and protected health information for purposes permitted by applicable state and federal law, including but not limited to treatment and payment.
Patient Name Name of Personal Representative (If Applicable)
Patient Signature Signature of Personal Representative (If Applicable)
Description of Personal Representative’s Authority (If applicable):