THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Use and Disclosure of Health InformationHope Healthcare (Hope) 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. Hope 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. Hope may use your health information to coordinate care within Hope and with others involved in your care, such as your attending physician, members of Hope’s interdisciplinary team, and other health care professionals who have agreed to assist Hope in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Hope also may disclose your health care information to individuals outside Hope 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. Hope may include your health information in invoices to collect payment from third parties for the care you receive from Hope. For example, Hope may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Hope. Hope 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. Hope may use and disclose health information for its own operations in order to facilitate the function of Hope and as necessary to provide quality care to all of Hope’s patients. Health care operations include such activities as:
For example, Hope 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, to confirm your patient status to facilitate giving a donation in your name, or to contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).
Hope may disclose certain information about you in a hospice directory while you are in Hope inpatient facility, including your name, your general health status, your religious affiliation, and where you are in Hope’s facility. Hope 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. Hope 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 to raise money for Hope unless you tell us you do not wish to be contacted. If you do not want Hope to contact you or your family, you can obt-out via phone or email to the Privacy Officer listed on the last page and indicating that you and/or your family members do not wish to be contacted.
For Appointment Reminders. Hope 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. Hope may use and disclose our 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 also may be used and disclosed.
When Legally Required. Hope 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. Hope may disclose your health information for public activities and purposes in order to:
To Report Abuse, Neglect, or Domestic Violence. Hope is allowed to notify government authorities if Hope believes a patient is the victim of abuse, neglect, or domestic violence. Hope 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. Hope may disclose your health information to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure, or disciplinary action. Hope, 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. Hope 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 Hope 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, Hope may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:
To Medical Examiners. Hope 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. Hope may disclose your health information to funeral directors consistent with applicable laws and, if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Hope may disclose your health information prior to and in reasonable anticipation of your death.
For Organ, Eve, or Tissue Donation. Hope 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. Hope may, under very select circumstances, use your health information for research. Before Hope discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Hope 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. Hope may, consistent with applicable laws and ethical standards of conduct, disclose your health information if Hope, 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, Federal regulations authorize Hope to use or disclose your health information to facilitate specified government functions relating to military, veteran, 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. Hope may release your health information for worker’s compensation or similar programs.
Other than is stated above, Hope will not disclose your health information without your written authorization. If you or your representative authorizes Hope 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 Hope 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 Hope’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Hope is not required to agree to your request. You also have the right to restrict certain disclosures of protected health information to a health plan where an individual pays out of pocket in full for the health care item or service. If you wish to make a request for restrictions, please contact the Privacy Officer listed on the last page.
Right to receive confidential communications. You have the right to request that Hope Healthcare communicates with you in a certain way. For example, you may ask that Hope 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 Privacy Officer listed on the last page. Hope 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 Privacy Officer listed on the last page. If you request a copy of your health information, Hope may charge a reasonable fee for copying and assembling costs associated with your request.
Right to amend health care information. You or your representative has the right to request that Hope 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 Hope. A request for an amendment of records must be made in writing to the Privacy Officer listed on the last page. Hope 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 Hope, if the records you are requesting are not part of Hope’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 Hope, the records containing your health information are accurate and complete.
Right to receive an accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Hope for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Privacy Officer listed on the last page. 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. Hope will provide the first accounting request you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
Right of affected individuals to be notified following a breach. You or your representative have the right to receive notification if there is a breach of your unsecured protected health information.
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 has previously requested a paper copy or an electronic copy. To obtain a separate paper copy, please contact the Privacy Officer listed on the last page. The patient or a patient’s representative may also obtain a copy of the current version of Hope’s Notice of Privacy Practices at its website, www.HopeHCS.org.
Hope is required by law to maintain the privacy of your health information and to provide to you or your representative this Notice of its duties and privacy practices. Hope is required to abide by the terms of this Notice as may be amended from time to time. Hope 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 Hope changes its Notice, Hope 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 Hope and to the Secretary of Department of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to Hope should he made in writing to the Privacy Officer listed below under “Contact Person” and/or:
The Guidance LineHospice Compliance NetworkP.O. Box 104Penfield, NY 14256(585) 671-8430 or (888) 765-7408
Community Health Accreditation Program: CHAP(800) 656-9656
Agency for Healthcare Administration: AHCA(850) 245-4339 or (888) 419-3456
Hope 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.
Hope has designated a contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact Hope’s Privacy Officer at:
Privacy OfficerHope Healthcare9470 HealthPark CircleFort Myers, FL 33908(239) 425-9898 or (888) 892-8908
This Notice is effective April 14, 2003.
Form #1348, rev. 11/2016
Hope Hospice and Community Services, Inc. is registered with the Florida Department of Consumer Services, registration number SC-01911. Please be advised that 100% of the donations we receive benefit Hope Hospice and are not directed to other organizations or entities. You may obtain a copy of our official registration and financial information by calling the Division of Consumer Services, toll-free within the State of Florida, at 1-800-435-7352.This registration does not imply endorsement, approval or recommendation by the State.
For copies or transfers of medical records, send a request to ProcessingDesk@HopeHCS.org
Hospice License #5010096
9470 HealthPark CircleFort Myers, FL 33908Toll-free: 800-835-1673Phone: 239-482-4673Fax: 239-482-6259
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Last Updated March 4th, 2022