This notice describes how medical information about you may be used and disclosed TO CARRY OUT TREATEMNT, PAYMENT OR HEALTH CARE OPERATIONS AND FOR OTHER PURPOSES THAT ARE PERMITTED OR REQUIRED BY LAW. iTALSO DESCRIBES YOUR RIGHT TO ACCESS AND CONTROL YOUR PROTECTED HEALTH INFORMATION. “pROTECTED HEALTH INFORMATION” IS INFORMATION ABOU TYOU, INCLUDIDNG EDMOGRAPHIC INFORMATION, THAT MAY IDENTIFY YOU AND THAT RELATES TO YOUR PAST PRESENT OR FUTURE PHYSICAL OR MENTAL HEALTH CONDITION AND RELATED HEALTH CARE SERVICES.‘PLEASE REVIEW IT CAREFULLY’USE AND DISCLOSURE OF HEALTH INFORMATION. Hospice and Palliative Care of Tidewater, herein referred to as HPCT, 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, EPHI and HITECH ACT, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. HPCT has established policies to guard against unnecessary disclosure of your health information. Patient written authorization is required to disclose any personal health information related to psychotherapy, marketing purposes and disclosures that constitute a sale of your personal health information. You may revoke this authorization, at any time, in writing, expect to the extent that HPCT has taken action in reliance on the use or disclosure indicated in the authorization.THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED BASED ON YOUR WRITTEN CONSENT: To Provide Treatment. HPCT may use your health information to coordinate care within HPCT and with others involved in your care, such as your attending physician, members of HPCT interdisciplinary team and other health care professionals who have agreed to assist HPCT in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. HPCT also may disclose your health care information to individuals outside of HPCT involved in your care including family members, clergy who you have designated, pharmacists, suppliers of medical equipment or other health care professionals. To Obtain Payment. HPCT may include your health information in invoices to collect payment from third parties for the care you receive from HPCT. For example, HPCT may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or HPCT. HPCT 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. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of HPCT. These activities include, but are not limited to, quality assessment activities, accrediting bodies, licensing, marketing activities and conducting or arranging any agency services for other business activities and operations.For example, we may use or disclose your protected health information, as necessary, to provide you with information about other agency health related benefits and services that may be of interest to you. We may use or disclose your protected health information to send you Client Satisfaction Surveys.We may disclose your protected health information to medical students and other students who are fulfilling their practicum requirement at our agency. Other permitted and required Uses and Disclosures That May be Made WITH Your Consent, Authorization or Opportunity to ObjectWe may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your health care professional may, using professional judgement, determine whether disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for the care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.Fundraising Activities. We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communicationsEmergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your healthcare provider or another healthcare provider in our agency is required by law to treat you and the healthcare provider has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your protected health information to treat you.Communication Barriers: We may use and disclose your protected health information if your health care professional or another health care professional at Jewish Family Service attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the health care professional determines, using professional judgement, that you intend to consent to use or disclose under the circumstances.Other Permitted and Required Uses and Disclosures That May Be Made WITHOUT Your Consent, Authorization, or Opportunity to Object.We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. This disclosure will be made for the purpose of controlling disease, injury, or disability. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information.Food and Drug Administration: We may disclose your protected health information to a company or person required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.Law Enforcement: We may disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. Coroners, Funeral Directors and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of the foreign military services.Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and Jewish Family Service created or received your protected health information in the course of providing care to you.Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq.As a recipient of Federal Financial assistance, HPCT does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by HPCT directly or through a contractor or any other entity with whom HPCT arranges to carry out its program and activities.YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information that HPCT maintains: The right to request restrictions. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your health care provider is not required to agree to a restriction that you may request. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request. Right to receive confidential communications. You have the right to request that HPCT communicate with you in a certain way. For example, you may ask that HPCT only conduct communications pertaining to your health information with you privately with no other family members present. HPCT will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications. Please make this request in writing to our Privacy Contact. Right to inspect and copy your health information. You have the right to inspect and copy your protected health information that is contained in a designated record set for as long as we maintain the protected health information, including billing records. If you request a copy of your health information, HPCT may charge a reasonable fee for copying and assembling costs associated with your request.A “designated record set” contains medical and billing records and any other records that your health care professional and HPCT uses for making decisions about you.Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medial record. Right to amend healthcare information. You or your representative has the right to request that HPCT 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 HPCT. HPCT 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 HPCT, if the records you are requesting are not part of HPCT’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 HPCT, the records containing your health information are accurate and complete. . If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record. Right to an accounting. You or your representative has the right to request an accounting of disclosures of your health information made by HPCT for certain reasons, including reasons related to public purposes authorized by law and certain research. The request should specify the time period for the accounting. Accounting requests may not be made for periods of time in excess of six (6) years. HPCT 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.If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.Right to be notified following a data breach of personal health information 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 has received this notice previously. HPCT 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. HPCT is required to abide by the terms of this Notice. HPCT reserves the right to change the terms of its Notice and to amend it from time to time. HPCT reserves the right to make the new Notice provisions effective for all health information that it maintains at that time. If HPCT changes its Notice, HPCT will provide a copy of the revised Notice to you or your appointed representative by accessing our website at www.hpctideweater.com, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next visit from staff. You or your personal representative has the right to express complaints to HPCT and to the Secretary of DHHS if you or your representative believes that your privacy rights have been violated. Any complaints to HPCT should be made in writing. HPCT 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. HPCT has designated a contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. Effective date. This notice is effective 9/2013. If you have any questions about this Notice you may call the number listed below or email us at: firstname.lastname@example.org. If you believe your privacy rights have been violated, you can file a complaint with the HPCT Privacy Officer or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. Contact information for both is listed below.Hospice and Palliative Care of Tidewater Privacy Officer:Patient Care AdministratorJessica J. Willingham, RN, BSN260 Grayson RdVirginia Beach, VA 23462TDD 1 757-321-2242 Office for Civil Rights:U.S. Department of Health and Human Services200 Independence Avenue, S.W.Room 509F, HHH BuildingWashington, D.C. 20201 This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975,and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84, and 91.