Hospice of the Golden Isles

Notice of Privacy Practices

Hospice of the Golden Isles, Inc. understands that your health information is personal, and we are committed to safeguarding your privacy. Please read this notice carefully as it describes how Hospice of the Golden Isles, Inc. will use and disclose your Protected Health Information (PHI). Hospice of the Golden Isles, Inc. (hereafter referred to as “Hospice”) may use your health information, information that constitutes protected health information as defined in the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, for the purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Hospice has established policies to guard against unnecessary disclosure of your health information. The following is a summary of the purposes and circumstances in which your health information may be used and disclosed: To Provide Treatment. Hospice may use your health information to coordinate care within 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 Hospice is coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medication. Hospice also may disclose your health care information to individuals outside Hospice involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals. To Obtain Payment. Hospice may include your health information in invoices to collect payment from third parties for the care you receive from Hospice. For example, Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Hospice. Hospice also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for Hospice care and the services that will be provided to you. To Conduct Health Care Operation. Hospice may use and disclose health information for its own operations in order to facilitate the function of Hospice and as necessary to provide quality care to all of Hospice’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 review, medical review, legal services and compliance programs.
• Business planning and development including cost management and planning related analyses and formulary development.
• Fundraising for the benefit of Hospice

For example, 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 contract 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). Hospice may disclose certain information about you including your name, your general health status, where you are in the Hospice inpatient or residential facility. Hospice may disclose this information to people who ask for you by name. Please inform us if you do not want your information disclosed. When Legally Required. 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 conduct of public health surveillance, investigation and intervention.
• 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. Hospice is required to notify government authorities if Hospice believes a patient is the victim of abuse, neglect or domestic violence. To Conduct Health Oversight Activities. Hospice may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. 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. 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 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, 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 Hospice has a suspicion that your death was the result of criminal conduct.
• In an emergency in order to report a crime.

To Coroners and Medical Examiners. 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. Hospice may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to funeral arrangements prior to and in reasonable anticipation of your death. For Organ, Eye or Tissue Donation. 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 tissues for the purpose of facilitating the donation and transplantation. For Research Purposes. Hospice may, under very select circumstances, use your health information for research. Before 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. Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if 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 Hospice to use and enclose 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.

AUTHORIZATION TO USE OR DISCLOSE HEATLH INFORMATION:

Other than is stated above, Hospice will not disclose your health information other than with your authorization. If you or your representative authorizes Hospice 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 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 Hospice’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the Director of Patient Services at Hospice. Right to receive confidential communications. You have the right to request that Hospice communicate with you in a certain way. For example, you may ask that 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 the Director of Patient Services at (912) 265-4735. Hospice will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communication. 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 Director of Patient Services at (912) 255-4735. If you request a copy of your health information, Hospice may charge a reasonable fee for copying and assembling cost associated with your request. Right to a paper copy of this notice. You or your legal representative has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact the Director of Patient Services at (912) 265- 4735.

DUTIES OF THE HOSPICE

Hospice is required by law to maintain the privacy of your health information and to provide to you and your representative the Notice of its duties and privacy practices. Hospice is required to abide by the terms of this Notice, which may be amended from time to time. Hospice reserves the right to change the terms of its notice and make the new notice provision effective for all health information that it maintains. If Hospice changes its Notice, Hospice will provide a copy of the revised Notice to you or your appointed representative. You or your legal representative has the right to express complaints to Hospice at (912) 265-5468 and to the Secretary of Department of Health & Human Services if you or your legal representative believes that your privacy rights have been violated. Any complaint to Hospice should be made in writing to Privacy Office, . Hospice encourages you to express any concerns you may have regarding the privacy of your information. There will be no retaliation against you for filing a complaint.

CONTACT PERSON

Hospice has designated the Director of Patient Services as its contact person for all issues regarding patient privacy and your rights under the Federal Privacy standards. You may contact this person at .

EFFECTIVE DATE

This notice is effective January 1, 2012.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER AT (912) 265-4735.