Hospice of Dayton, Inc.
Notice of Privacy Practices
Effective April 14, 2003

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.

Hospice of Dayton (HOD) uses protected health information (“PHI”) about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your PHI is contained in medical and billing records that are the physical property of HOD and which may identify you or may describe or be related to your past, present or future physical and mental health.

HOD is required by law to:

• Maintain the privacy of PHI;
• Provide you with this notice of its legal duties and privacy practices with respect to your PHI;
• Abide by the terms of this notice;
• Notify you if we are unable to agree to a requested restriction on how your PHI is used or disclosed;
• Accommodate reasonable requests you may make to communicate PHI by alternative means or at alternative locations; and
• Obtain your written authorization to use or disclose your PHI for, reasons other than those listed herein and permitted under law.

HOD reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available by:

• Current patients will receive revised notices from a member of the interdisciplinary team,
• Posting on the HOD website,
• Posting within the HOD facility.

HOW HOSPICE OF DAYTON MAY USE OR DISCLOSE YOUR HEALTH INFORMATION:

1. For Treatment.
HOD may use your PHI to provide you with medical treatment or services or provide your PHI to other health care providers who are involved in taking care of you. For example, a health care provider, such as HOD, a physician, nurse, or other person providing health services to you, will record PHI in your record that is related to your treatment. This information is necessary for these health care providers to determine what treatment you should receive. This PHI may also be provided to other health care providers so that they can treat you. HOD will ask you to sign a consent to provide treatment and to permit this disclosure.

2. For Payment.
HOD may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.

3. For Health Care Operations.
HOD may use and disclose PHI about you for the business of HOD operations. For example, your PHI may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

• Evaluate the performance of our staff;
• Assess the quality of care and outcomes in your cases and similar cases;
• Learn how to improve our facilities and services;
• Determine how to continually improve the quality and effectiveness of the health care we provide; and
• Type out notes and documents to help HOD keep good records.

4. Appointments.
HOD may use your PHI to provide appointment reminders who you may be waiting to see or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

5. Fund Raising.
HOD may use your PHI to contact you to raise funds for HOD.

6. Group Health Plans.
A group health plan, health insurance issuer, or HMO with respect to a group health plan may disclose PHI to the sponsor of the plan.

7. Required by Law.
HOD may use and disclose PHI about you as required by law. For example, HOD may disclose information for the following purposes including:

• For judicial and administrative proceedings pursuant to legal authority;
• To report information related to victims of abuse, neglect or domestic violence; and
• To assist law enforcement officials in their law enforcement duties.

8. Public Health.
Your PHI may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

9. Decedents.
PHI may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

10. Organ/Tissue Donation.
Your PHI may be used or disclosed for cadaver organ, eye or tissue donation purposes.

11. Research.
HOD may use or disclose to others your PHI for research purposes and with you authorization when an institutional review board or privacy board that has reviewed the research proposal, and established protocols to ensure the privacy of your health information has approved the research.

12. Health and Safety.
Your PHI may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

13. Government Functions.
Your PHI may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

14. Workers' Compensation.
Your PHI may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation.

15. Other Uses.
Other uses and disclosures will be made only with your written authorization and you may revoke the authorization except to the extent HOD has taken in reliance on such.

YOUR HEALTH INFORMATION RIGHTS

You have the right to:

• Request a restriction on certain uses and disclosures of your PHI, which must be submitted in writing on forms to be provided by HOD; HOD, however, is not required to agree to a requested restriction;
• For treatment, payment, or health care operations, you may also request a limit on the PHI that may be disclosed about to someone who is involved in your care or payment for your care;
• Obtain a paper copy of the notice of privacy practices for any reason upon request to HOD;
• Inspect and obtain a copy of your health record containing PHI using the request form we furnish to you. We will notify you in writing using a HOD form within 60 days of our decision, including our rejection of your request. You may appeal this request. You may also be charged for any copies of PHI provided to you;
• Amend your health record using a form prepared by HOD;
• Request communications of your health information by alternative means or at alternative locations which HOD will accommodate on a reasonable basis;
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken; and receive an accounting of disclosures made of your health information as provided by 45 CFR §164.528.

COMPLAINTS

You may complain to Hospice of Dayton and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

Contact Information
If you have any questions or complaints, please contact:
Privacy Officer
Hospice of Dayton
324 Wilmington Avenue
Dayton, OH 45420
Phone: (937) 256-4490