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(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) (HIPAA), for
purposes of providing you treatment and conducting
health care operations.
USE
AND DISCLOSURE OF HEALTH INFORMATION
Cross Timbers Hospice (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) (HIPAA), for
purposes of providing you treatment and conducting
health care 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
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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 may also disclose your health care
information to individuals outside of the
Hospice involved in your care including family
members, clergy who you have designated,
pharmacists, suppliers of medical equipment or
other health care professionals. |
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To
Obtain Payment From Third Parties. 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 may also 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. |
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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 includes
such activities as: |
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Quality
assessment and improvement activities |
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Activities
designed to improve health or reduce health care
costs |
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Protocol
development, case management and care
coordination |
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Contacting
health care providers and patients with
information about treatment alternatives and
other related functions that do not include
treatment |
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Professional
review and performance evaluation |
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Training
programs including those in which students,
trainees or practitioners in health care learn
under supervision |
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Training
of non-health care professionals |
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Accreditation,
certification, licensing or credentialing
activities |
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Review
and auditing, including compliance reviews,
medical reviews, legal services and compliance
programs |
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Business
planning and development including cost
management and planning related analyses and
formulary development |
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Business
management and general administrative activities
of the Hospice |
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For
example, the Hospice may use your health
information to evaluate its staff performance,
combine your health information with other
Hospice patients in statistical form to evaluate
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 community
information mailings (unless you tell us you do
not want to be contacted). |
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For
Appointment Reminders. The Hospice may use
and disclose your health information to contact
you to set an appointment for a home care visit,
or as a reminder that you have such an
appointment. |
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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
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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. |
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To
Conduct Health Oversight Activities.
The Hospice may disclose your health
information to a health oversight authority 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. |
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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 court order 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. |
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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: |
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As
required by law for reporting certain types of
wounds or other physical injuries pursuant to
the court order or similar process |
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For
the purpose of identifying or locating a
suspect, fugitive, material witness or missing
person |
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Under
certain limited circumstances, when you are the
victim of a crime |
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If
the Hospice has a suspicion that your death was
the result of criminal conduct including
criminal conduct at the Hospice |
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In
an emergency in order to report a crime |
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To
Coroners And Medical Examiners.
The
Hospice may disclose your health information to
coroners and medical examiners for the purposes
of determining your cause of death or for other
duties as authorized by law |
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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 an
in reasonable anticipation of your death. |
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To
Florists At The Time of Your Death.
The
Hospice may disclose your health information to
a florist at the time of your death in order to
provide a floral tribute from the Hospice at the
time of your funeral service |
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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 when this has been
specifically identified as your wish after death |
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For
Research Purposes.
The
Hospice may, under very select circumstances,
use your health information in statistical form,
for research. Before the Hospice discloses
any of your health information for this purpose,
it will be with your specific permission and the
project will be subject to an extensive approval
process |
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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. |
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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, national security and
intelligence activities, protective services for
the President and others, medical suitability
determinations and inmates and law enforcement
custody. |
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For
Workers' Compensation.
The
Hospice may release your health information for
workers' 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:
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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 the Compliance Officer at the
Hospice. |
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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 the Compliance Officer at the Hospice in
writing or by phone at 580-223-0655 or
1-800-498-0655. The Hospice will not
request that you provide any reasons for your
request and will attempt to honor your
reasonable requests for confidential
communications. |
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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 Compliance Officer at the Hospice
in writing or by phoning 580-223-0655 or
1-800-498-0655. 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. |
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Right
to Amend Health Care Information.
You,
or your representative, have 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 the
Compliance Officer at the Hospice and mailed to Compliance
Officer, Cross Timbers Hospice, 207 C Street,
NW, Ardmore, Oklahoma 73401. 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 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. |
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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 the Compliance Officer, Cross
Timbers Hospice, 207 C Street, NW, Ardmore,
Oklahoma 73401. The request should specify
the time period for the accounting starting on
or after April 14, 2003. Accounting
request may not be made for periods of time in
excess of seven (7) 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. |
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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, pleas contact the Compliance Officer
at 580-223-0655 or 1-800-498-0655. You may
also obtain a copy of the current version of the
Hospice's Notice of Privacy Practices at its
website, www.crosstimbershospice.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 the
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 it 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 the Compliance
Officer, Cross Timbers Hospice, 207 C Street, NW,
Ardmore, Oklahoma 73401. 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 has designated a
Compliance Officer as its contact person for all issues
regarding patient privacy and your rights under the
Federal privacy standards. You may contact this
person at Cross Timbers Hospice,
207 C Street, NW, Ardmore,
Oklahoma 73401 or by phone at 580-223-0655 or
1-800-498-0655.
EFFECTIVE
DATE
This
Notice is effective April 14th
2003
IF
YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE
CONTACT:
Compliance
Officer
Cross
Timbers Hospice
207
C Street, NW
Ardmore,
Oklahoma 73401
Or
you may phone at:
580-223-0655
or 1-800-498-0655
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