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

Hospice of Siouxland 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. Hospice of Siouxland 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 YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. Hospice of Siouxland may use and disclose 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 in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Hospice of Siouxland also may disclose your health care information to individuals outside of Hospice involved in your care including family members, clergy, pharmacists, suppliers of medical equipment or other health care professionals/organizations.

To Obtain Payment. Hospice of Siouxland 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 Operations. Hospice of Siouxland 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 includes 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.
• 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 Hospice.
• Activities to advance Hospice care such as fundraising and promotion of Hospice services

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 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. Hospice of Siouxland 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 for charitable giving to Hospice. If you do not want Hospice of Siouxland to contact you or your family, notify the Hospice Fund Development Coordinator at (712) 233-4144 and indicate that you do not wish to be contacted.

To Arrange Needed Community Resources. Hospice of Siouxland may disclose your health information to arrange services for you from other community agencies that you have agreed to, such as Meals on Wheels or Aging Services, etc.

For Treatment Alternatives. Hospice of Siouxland may use and disclose your health information to obtain information about 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. Hospice of Siouxland 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. Hospice of Siouxland 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. Hospice of Siouxland is required to notify government authorities if Hospice believes a patient is the victim of abuse, neglect or domestic violence. Hospice will make this disclosure only when specifically required or authorized by law or when the patient requests the disclosure.

To Conduct Health Oversight Activities. Hospice of Siouxland may disclose your health information to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. However, Hospice, 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 of Siouxland 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 of Siouxland 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 of Siouxland 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 of Siouxland 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, Hospice may disclose your health information prior to and in reasonable anticipation of your death.

For Organ, Eye Or Tissue Donation. Hospice of Siouxland 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. Hospice of Siouxland may, under very select circumstances, use and disclose 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 of Siouxland 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 of Siouxland 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. Hospice of Siouxland may release your health information for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated above, Hospice of Siouxland will not disclose your health information other than with your written authorization. If you or your representative authorizes Hospice of Siouxland 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 of Siouxland 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 Clinical Specialist at (712) 233-4144.
• 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 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 the Clinical Specialist at (712) 233-4144. 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 the Clinical Specialist at (712 233-4144). If you request a copy of your health information, Hospice 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 Hospice of Siouxland 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 Hospice. A request for an amendment of records must be made in writing to: Clinical Specialist, 4300 Hamilton Blvd., Sioux City, IA. 51104 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 Hospice of Siouxland, if the records you are requesting are not part of 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 Hospice, 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 for purposes other than treatment, payment or health care operations, made by Hospice of Siouxland 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: Clinical Specialist, 4300 Hamilton Blvd., Sioux City, IA. 51104. 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. 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.
• 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: Clinical Specialist at (712 233-4144). 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, http://www.hospiceofsiouxland.org.

DUTIES OF HOSPICE

Hospice of Siouxland 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 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 Hospice changes its Notice, Hospice will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative has the right to express concerns to Hospice and to the Secretary of Department of Health and Human Services (DHHS) if you or your representative believes that your privacy rights have been violated. Any concerns to Hospice should be made in writing to: Clinical Specialist, 4300 Hamilton Blvd., Sioux City, IA. 51104 Hospice 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 concern.

CONTACT PERSON

Hospice of Siouxland has designated the Clinical Specialist as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at Hospice of Siouxland, 4300 Hamilton Blvd., Sioux City, IA. 51104. Phone: (712) 233-4144.

EFFECTIVE DATE

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE,
PLEASE CONTACT:
Clinical Specialist
Hospice of Siouxland
4300 Hamilton Blvd.
Sioux City, IA 51104
Phone: (712) 233-4144