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
LifePath Hospice Care Services, LLC (“Hospice”) 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 operations. The Hospice 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. 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 agreed to assist
the Hospice in coordinating care. 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, pharmacists, suppliers of medical equipment or other health care professionals.
To Obtain Payment. The Hospice may include your health information in invoices to collect payment from third parties for the care you
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 prior approval from your insurer and may need to explain to the
insurer your need for hospice and the services that will be provided to you.
To Conduct Health Care Operations. The Hospice may use and disclose health 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 include 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 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.
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 contact you as a reminder
regarding a visit to you, (unless you tell us you do not want 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.
For Treatment Alternatives. The Hospice may use and disclose your 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 MAY ALSO BE USED AND
DISCLOSED.
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, 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. The Hospice is allowed 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 are 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 permitted or required by State law, the Hospice 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 law enforcement officials if the Hospice has a suspicion that your death was the result of 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.
For Research Purposes. The Hospice may, under very select 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.
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 Specific 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, 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. 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 Freda Sims,
RN/Administrator at 318-222-5711.
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 Freda Sims, RN/Administrator at 318-222-5711. 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 Freda Sims, RN/Administrator at 318-222-5711. 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. You or your representative has the right to request that the Hospice 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 the Hospice.
A request for an amendment of records must be made in writing to Freda Sims, RN/Administrator, 1500 N. Market, Suite B-108, Shreveport, Louisiana 71107.
The 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 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 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 Freda Sims, RN/Administrator, 1500 N. Market, Suite B-108, Shreveport, Louisiana 71107. The request should
specify the time period for the accounting starting on or after April 14th, 2003. Accounting requests may not be made for periods of time in excess
of six (6) years. The 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 has a right to a separate copy of this Notice at any given time even
if you or your representative has received this Notice previously. To obtain a separate copy, please contact Freda Sims, RN/Administrator at
318-222-5711.
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 the terms of this Notice as may be amended from time to time. The Hospice reserves the right
to change 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 DHHS if you or your representative believes that your privacy rights have been violated.
Any complaints to the Hospice should be made in writing to Freda Sims, RN/Administrator, 1500 N. Market, Suite B-108, Shreveport, Louisiana 71107. T
he 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 has designated Freda Sims, RN/Administrator, as its contact person for all issues regarding patient privacy and your rights under the
Federal privacy standards. You may contact this person at 1500 N. Market, Suite B-108, Shreveport, Louisiana 71107.
EFFECTIVE DATE
This Notice is effective April 14th, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
Freda Sims, RN/Administrator, 1500 N. Market, Suite B-108, Shreveport, Louisiana 71107.
