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:

To Provide Treatment: 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) pharmacists; suppliers of medical equipment, laboratory and radiology services; and clergy. Family and caregivers will be informed and utilized in the coordination of care, unless specifically excluded by you.

To Obtain Payment: For example, Promise Hospice, Inc. (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 Healthcare Operations: 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 Veterans Affairs, State Veteran’s Commission, 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 analyses and formulary development
• Business management and general administrative activities of the hospice
• Patient safety activities (as defined in 42CFR 3.20).

Communication and Marketing: Except as permitted by law, the hospice will not use your PHI for marketing purposes without your prior written authorization. We may discuss face-to-face or offer a promotional gift of nominal value without authorization.

FEDERAL PRIVACY RULES ALLOW THE HOSPICE TO USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION FOR A NUMBER OF REASONS:

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 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 product recalls, repairs and replacements and to comply 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 mandated to notify government authorities if it believes a patient is the victim of abuse, neglect, or domestic violence.

To Conduct Health Oversight Activities: The 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. 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 required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena, 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, 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.

For Specified Government Functions: The hospice may make disclosure to facilitate specified government functions relating to military and veterans, national security, intelligence activities, and protective services for the President and others.

For Workers Compensation: The hospice may release your health information for worker’s compensation or similar programs.

For Other Covered Entities or Business Associates: The hospice may disclose personal information to other covered entities or business associates. We will only share your personal information with third parties as outlined in this Privacy Policy (in its current or future form) and as otherwise permitted by law. For example, we may disclose information to government entities, if it has been arranged for us to do so, in order to assist in determining state or federal benefit programs such as Medicaid and Medicare.

Sale of Your PHI: Except as permitted by law, we will not sell your PHI for financial remuneration without your prior written authorization.

For Fundraising: We may contact you as part of our fund raising efforts and disclose for fundraising activities your contact information, dates of service, health insurance status, department of service information, name of treating physician, and outcome information. Such disclosures would be to associates of, or a foundation related to, the hospice. You have the right to opt out of receiving such communications.

MOST USES AND DISCLOSURES OF PSYCHOTHERAPY NOTES, USES AND DISCLOSURES OF HEALTH INFORMATION FOR MARKETING PURPOSES, AND DISCLOSURES THAT CONSTITUTE A SALE OF HEALTH INFORMATION WILL BE MADE ONLY WITH YOUR WRITTEN AUTHORIZATION. OTHER USES AND DISCLOSURES OF HEALTH INFORMATION NOT COVERED BY THIS NOTICE WILL BE MADE ONLY 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.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION:

• The right to receive confidential communications i.e. with no other family members present
• The right to request restrictions on certain disclosures of your health information, as provided by 45 CFR 164.522. The hospice is not required to agree to such disclosures, except for requests to restrict disclosures to a health plan if the disclosure is for payment or health care operations and pertains solely to a health care item or service for which you (or person other than the health plan on your behalf) has paid your health care provider out of pocket in full. If the hospice does agree, it will comply with your request unless the information is needed to provide you emergency treatment
• The right to inspect and copy your health information, including billing records, as provided by 45 CFR 164.524, however the hospice may charge a reasonable fee for copying and assembling costs associated with your request
• The right to amend health care information if you or your representative believes that your health information records are incorrect or incomplete, however the hospice is not required to agree, as provided in 45 CFR 164.526
• The right to an accounting of disclosures of your health information made by the hospice for any reason other than for treatment, payment or health operations, as provided in 45 CFR 164.528; and The right to a paper copy of this notice even though you had previously received a copy.

To exercise any of the above rights, please contact the Hospice Administrator.