Thursday, 25th of May 2017

Privacy

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

Information that constitutes as protected health information is defined in the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996. Hospice For Utah (HFU) understands the security of your protected health information is an important concern. We take the protection of your personal data very seriously and provide training regarding patient privacy to all employees. We would like to inform you about our security measures with this privacy statement. HFU may use your health information for purposes of providing you treatment, obtaining payment, and conducting health care operations. HFU has established policies to guard against unnecessary disclosure of your protected health information.

The following is a summary of the circumstances under which your health information may be used and disclosed:

To Provide Treatment: HFU may use your health information to coordinate care to those involved in your care, such as your attending physician, members of the HFU interdisciplinary team and other health care professionals who have agreed to assist in coordination of care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. HFU may also disclose your health care information to individuals outside of HFU involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment: HFU may use your health information to collect payment from third parties for the care you receive. For example, HFU may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse HFU. HFU may also need to obtain prior approval from your insurer and/or explain to the insurer your need for hospice and the services that will be provided to you.

To Conduct Health Care Operations:
HFU may use and disclose health information for its own operations in order to provide quality care to all of HFU’s 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, 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 analyses and formulary development.
• Business management and general administrative activities of HFU.
• Fundraising for the benefit of HFU, unless you choose to opt out.

For example, HFU may use your health information to evaluate its staff performance; to combine your health information with other hospice patients in evaluating how to more effectively serve all hospice patients; to disclose your health information to hospice staff and contracted personnel for training purposes; to contact you as a reminder regarding a visit to you; to contact you as a part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).

HFU may disclose certain information about you including your name, general health status, religious affiliation, and in a hospice directory while you are in an inpatient facility.

HFU 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.

For Fundraising Activities: HFU may use information about you including your name, address, phone
number and the dates you received care in order to contact you to raise money for HFU (unless you tell us
you do not wish to be contacted). HFU will only use your personal health information for marketing
purposes or sell your information if authorization is received prior to use.

For Appointment Reminders: HFU may use and disclose your health information to contact you as a
reminder that you have an appointment for a home visit.

For Treatment Alternatives: HFU 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:

When Legally Required: HFU may 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: HFU may disclose your health information for public activities and purposes in order to:

• Prevent or control disease, injury or disability, report disease, 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.

To Report Abuse, Neglect or Domestic Violence: HFU is required to notify government authorities if the
hospice believes a patient is the victim of abuse, neglect or domestic violence. HFU 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: HFU may disclose your health information to a health oversight
agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or
disciplinary action. HFU, 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:
HFU 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. HFU must make reasonable efforts to 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, HFU 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 HFU has a suspicion that your death was the result of criminal conduct including criminal conduct at HFU.

• In an emergency in order to report a crime.

To Coroners and Medical Examiners: HFU 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: HFU 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, HFU may disclose your health information prior to and in reasonable anticipation of
your death.

For Organ, Eye or Tissue Donation: HFU 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 if such procedures are requested by
you.

For Research Purposes: HFU does not participate in research programs.

In the Event of a Serious Threat to Health or Safety: HFU may, consistent with applicable law and ethical standards of conduct, disclose your health information if HFU 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 regulation authorizes HFU 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: HFU may release your health information for worker’s compensation or similar programs.

Other uses and disclosures not described will be made only with your authorization.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
If you or your representative authorizes HFU to use or disclose your health information, you may revoke that authorization in writing at any time.

You have the following rights regarding your health information that HFU 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 HFU’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, HFU is not required to agree to your request. If you wish to make a request for restrictions please contact HFU Privacy Office.
Also, you may ask HFU to not disclose your personal health information to a health plan for payment where we have been paid in full, out of the pocket, at the time of the service. However, it is not the responsibility of HFU to notify downstream providers of the fact that you have requested a restriction on the disclosure of personal health information to a health plan. In accordance with the Genetic Information Nondiscrimination Act (GINA) of 2008, HFU considers genetic information personal health information and will not use it to determine eligibility for coverage of hospice services nor report to companies for underwriting purposes.

• Right to Receive Confidential Communications: You have the right to request that HFU communicate with you in a certain way. For example, you may ask that HFU 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 HFU Privacy Officer. HFU will not request that you provide any reasons for your request and will attempt to honor your reasonable request for confidential communications.

• Right to Inspect and Copy Your Health Information: You have the right to inspect and obtain a copy your health information, including billing records. A request to inspect and obtain a copy of records containing your health information may be made to HFU Privacy Officer. If you request a copy of your health information, HFU may charge a reasonable fee for copying and assembling costs associated with your request.

• Right to Request an Electronic Copy of Your Health Information: You have the right to request an electronic copy of your Health Information. A request to obtain an electronic copy of records containing your health information may be made to HFU Privacy Officer. HFU retains the right to provide such information in a text-based PDF version only. Your Health Information will be saved to a device and you will be required to pick up the device from HFU Privacy Officer. You may request that your records be sent over an unsecure email instead; however, HFU is not responsible for the potential breach of your health information. If you request a copy of your health information, HFU may charge a reasonable fee for copying and assembling costs associated with your request.

• Right to Amend Health Care Information: You or your representative, have the right to request that HFU 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 HFU. A request for an amendment of records must be made in writing to HFU. HFU 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 HFU, if the records you are requesting are not part of HFU’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 HFU, the records containing your health information are accurate and complete.

• Right to an Accounting: You or your representative have the right to request an accounting of disclosures of your health information made by HFU for certain reasons, including reasons related to public purposes authorized by law and certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting request may not be made for periods of time in excess of six (6) years for paper form. All disclosures made by electronic health record may be requested for three (3) years prior to the date of the request. HFU would provide the first accounting you request during any 12-month period without charge. Subsequent requests may be subject to reasonable costs

• Right to Notification of Breach: If HFU determines that there has been a breach of your protected health information, we will provide you or your representative with written notice by first class mail or by email if you agree to receive electronic notices. The notification will be provided no later than 60 days following the discovery of the breach. The notification will include a description of the breach; description of the type of information involved in the breach; the steps that you or your representative should take to protect you from harm; a brief description of what HFU is doing to investigate the breach, mitigate the harm, and prevent further breaches; and the contact information for HFU. HFU will notify you by telephone as well as written notice in cases deemed by HFU to require urgency because of possible imminent misuse of protected health information.

• Right to file grievances: You or your representative has the right to file grievances regarding your care at http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaint.html.

• Right to a Paper Copy of This Notice: You or your representative has a right to a separate copy of this Notice at any time even if you or your representatives have received this Notice previously. To obtain a separate paper copy, please contact HFU at the information below.

Duties of HFU

HFU 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. HFU is required to abide by the terms of this notice as may be amended from time to time. HFU reserves the right to change the terms of its notice and the new notice provisions effective for all health information that it maintains. If HFU changes its notice, HFU will provide a copy of the revisions to you or your appointed representative. You or your personal representative have the right to express complaints to HFU and to the Office of Civil Rights (1-800-368-1019) if you or your representative believe that your privacy rights have been violated. Any complaints to HFU should be made in writing to one of the addresses below. HFU 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 complaint.

CONTACT PERSON

Hospice For Utah has a designated administrator as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact:

Andrea Munier, Administrator

11639 S. 700 E. #100 5742 S Adams Ave Pkwy #C
Draper, UT 84020 Ogden, UT 84405
801-576-1455 801-621-6642

We'd love to hear from you.

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