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 San Joaquin (herein referred as Hospice) may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed only after the Hospice has obtained your written consent. The Hospice has established a policy to guard against unnecessary disclosure of your health information oriented to the protection of confidentiality of patient's health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT:

To provide treatment. The Hospice may use your health information to coordinate care within the 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 a contract agreement to assist the Hospice in providing services to you. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. The Hospice also may disclose your health care information to individuals outside of the Hospice involved in your care including family members you have designated, pharmacists, suppliers of medical equipment or other health care professionals when necessary.

To obtain payment. The Hospice may include your health information in invoices to collect payment from third parties for the care you may receive from the Hospice. For example, the Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Hospice. The Hospice also may need to obtain approval from insurer and explain to the in surer your need for hospice care and the services that will be provided to you.

To conduct health care operations. The Hospice may use and disclose health care information for its own operations in order to facilitate the function of the Hospice and as necessary to provide quality care to all of the 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.
  • Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
  • Professional review and perfomance 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.
  • Fundraising for benefit of the Hospice.

For example, the 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 by telephone or e-mail as a reminder regarding a visit to you, or contact you or your family as part of community information mailings (unless you tell us you do not want to be contacted)

The Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in the Hospice facility in a Hospice directory or list while you are in the Hospice inpatient facility. The hospice 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 or disclosed.

For fundraising activities. The Hospice may use information about you including your address and phone number in order to contact you or your family for fundraising events for Hospice of San Joaquin. If you do not want the Hospice to contact you or your family, notify our Director of Resource Development at (209) 957-3888 and indicate that you do not wish to be contacted.

For appointment reminders. The hospice may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit.

To refer patient to additional services. If the Hospice performing the initial assessment or reassessment identifies patient care findings that indicate a need for referral to appropriate services, it will refer the patient to these services. The services may include: physical therapy, occupational therapy, speech therapy, community-based mental health services, and community-based continuous care nursing services, and other non-health related.

FEDERAL PRIVACY RULES ALLOW THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES

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 in order to:

  • Prevent or control disease, injury or disability; report disease, injury or vital events such as birth or death and as part of public health surveillance, investigations and interventions.
  • To 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.
  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
  • To 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 required to notify government authorities if the Hospice believes a patient is the victim of abuse, neglect or domestic violence. The Hospice 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. 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.

For law enforcement purposes. The Hospice may disclose your health information to law enforcement official for 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 law enforcement officials if the 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. 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.

For research purposes. The Hospice may, under very selected circumstances, use your health information for research. Before the Hospice discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. The Hospice will ask your permission if any researcher will be granted access to your individually identifiable health information.

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. In certain circumstances, the Federal regulations authorize the Hospice to use or disclose your health information to facilitate specified government functions relating to military and veterans, those in law enforcement custody, and others.

For worker's compensation. The Hospice may release your health information for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated above, the Hospice will not disclose your health information other than 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

You have the following rights regarding your health information that the 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 the Hospice's disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact our designated Referral RN Case Manager at (209) 957-3888.

Right to receive confidential communications. You have the right to request that the 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 our designated Referral RN Case Manager at (209) 957-3888. The 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 our Director of Finance and Operations at (209) 957-3888. If you request a copy of your health information, the Hospice may charge a reasonable fee for copying and assembling costs associated with your request.

Right to amend health care information. If you or your representative believes that your health information records are incorrect or incomplete, you may request that the Hospice amend the records. That request may be made as long as the information is maintained by the Hospice. A request for amendment of records must be made in writing to our Director of Finance and Operations at 3888 Pacific Ave, Stockton, CA 95204. The Hospice may deny the request if it is not in writing or does not include a reason for amendment. The request also may be denied if your health information records were not created by the Hospice, if the records you are requesting are not part of the 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 the 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 made by the Hospice for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to our Director of Finance and Operations at (209) 957-3888. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for any period of time in excess of six years. The Hospice would provide the first accounting 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 has 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 our Director of Finance and Operations at (209) 957-3888 or visit our website at www.hospicesj.org

DUTIES OF THE HOSPICE

The Hospice 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. The Hospice is required to abide by terms of this Notice as may be amended from time to time. The 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 the Hospice changes its Notice, the 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 complaints to the Hospice and to the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 (202) 619-0257 Toll Free: 1-877-696-6775 if you or your representative believes that your privacy rights have been violated. Any complaints to the Hospice should be made in writing to our Executive Director at 3888 Pacific Ave, Stockton, CA 95204. The 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 complaint.

CONTACT PERSON

The Hospice's contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is our

Director of Finance and Operations at
3888 Pacific Ave, Stockton CA 95204
Phone Number (209) 957-3888.

EFFECTIVE DATE

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT OUR Director of Finance and Operations at
3888 Pacific Ave, Stockton CA 95204
Phone Number (209) 957-3888

3888 Pacific Avenue Stockton, California 95204-195324 hr. main-line: (209) 957-3888fax: (209) 957-3986