NOTICE Privacy Practices
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.
This notice describes how Ivy Hospice Care, Inc. and its employees, staff, volunteers, students and personnel may use or disclose your protected health information.
To obtain further information about matters covered in this notice or if you have any questions about this notice, please contact our Administrator at: (909) 931-5090
IVY HOSPICE CARE’S COMMITMENT TO PROTECTING THE CONFIDENTIALITY OF YOUR HEALTH INFORMATION
Ivy Hospice Care will, as required by law, abide by the terms of this notice and will provide this notice of our legal duties and privacy practices.
This notice applies to all of the medical records and information Ivy Hospice Care has about you, including information collected and gathered by Ivy Hospice Care as well as our volunteers and students. This notice does not, however, apply to other physicians, health care providers or third parties that have access to your personal medical information. For example, if you receive care from your personal physician for an ailment unrelated to your terminal illness, the medical information collected by your physician will not be governed by this notice. Instead, your personal doctor will have different policies or notices regarding his or her uses and disclosures of your medical information.
Ivy Hospice Care has established policies and procedures to guard against a breach of unsecured protected health information. Ivy Hospice Care will, as required, notify all affected parties should a breach occur in writing, either through e-mail or by the postal service within a reasonable amount of time after the breach is made known to Ivy Hospice Care.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that Ivy Hospice Care may use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways Ivy Hospice Care is permitted to use and disclose information will fall within one of these categories.
Ivy Hospice Care may use medical information about you to provide you with hospice services. Ivy Hospice Care may disclose medical information about you to members of its interdisciplinary team (IDT), to pharmacists or to your personal physicians. Ivy Hospice Care may disclose medical information about you to people outside Ivy Hospice Care who are involved in your medical care, such as hospitals, nursing facilities, doctors, nurses, pharmacies, family members involved in your care or other persons or organizations involved in your treatment. For example, if you are experiencing discomfort, we may contact your personal physician to discuss modifications to your medication. If your doctor prescribes a new medication, we may contact your pharmacist to ensure that this medication will not cause undesired side effects or otherwise interfere with your other medications.
Ivy Hospice Care may use and disclose medical information about you so that the hospice services we provide may be billed and payment collected. For example, Ivy Hospice Care may need to give your health plan information about services and supplies you have been prescribed and/or received from Ivy Hospice Care so your health plan will pay us for the provision of these services. Ivy Hospice Care may also disclose information about you to one of your other providers, including your personal physician, so that they may bill for the services they have or will provide to you.
Health Care Operations
Ivy Hospice Care may use and disclose medical information about you for purposes of our health care operations. These uses and disclosures are necessary to run Ivy Hospice Care and to ensure that all patients receive quality care and benefit from the collective Ivy Hospice Care knowledge. For example, Ivy Hospice Care may use medical information to review our treatment and services and to evaluate the performance of our staff in responding to your needs. Ivy Hospice Care may also use medical information about our patients to ascertain how Ivy Hospice Care can improve the hospice services we provide, what services are most important or beneficial to you or what services may need to be improved.
Ivy Hospice Care may use and disclose medical information to contact you as a reminder that you have an appointment scheduled or to tell you about treatment alternatives or other related benefits and services that may be of interest to you.
As Required By Law
Ivy Hospice Care will disclose medical information about you when we are required to do so by federal, state or local law. For example, Ivy Hospice Care may disclose medical information about you if you or another person in a protected group (child, dependent adult or elder) is the victim of abuse or neglect. We will only make this disclosure when specifically required or authorized by law.
To Avert a Serious Threat to Health or Safety
Ivy Hospice Care may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Ivy Hospice Care may ask to feature you or your loved ones in our newsletter, in a video, or in some other publication we prepare to explain hospice services generally and the special role Ivy Hospice Care fills. We will never include your name, except for listing any memorial contributions made in your honor, or otherwise feature you or your loved ones in any of our newsletters, videos, or other publications without first obtaining your prior written authorization.
Public Health Risks
Ivy Hospice Care may disclose medical information about you for public health activities. These activities generally include the following:
To prevent or control disease, injury or disability;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Ivy Hospice Care will only make this disclosure if you agree or when required or authorized by law.
In addition, Ivy Hospice Care may remove certain information that identifies you (such as name, address (other than zip code), social security number, etc.) from this set of medical information so others may use it for public health purposes without learning who the specific patients are; Ivy Hospice Care will obtain a written agreement from the recipient of your medical information that the recipient will only use the information for public health purposes.
Health Oversight Activities
Ivy Hospice Care may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Ivy Hospice Care may release medical information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, Ivy Hospice Care is unable to obtain your agreement;
About a death Ivy Hospice Care believes may be the result of criminal conduct;
About criminal conduct at Ivy Hospice Care;
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime;
To notify coroner, medical examiner and funeral director;
For matters of national security and intelligence activities; or
To law enforcement officials if you are an inmate of a correctional institution or under the custody of law enforcement.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have a number of rights regarding medical information that Ivy Hospice Care maintains about you.
Right to Inspect and Copy
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, please submit your request in writing to Ivy Hospice Care at the address printed on the first page of this notice. If you request a copy of the information, Ivy Hospice Care may charge a fee for the costs of copying, mailing or other services and supplies associated with your request.
We may deny your request to inspect and copy your medical information in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Ivy Hospice Care will review your request and the denial. The person conducting the review will not be the person who denied your request. Ivy Hospice Care will comply with the outcome of the review.
Right to Amend
If you feel that medical information Ivy Hospice Care has about you is incorrect or incomplete, you may ask Ivy Hospice Care to amend the information. You have the right to request an amendment for as long as the information is kept by or for Ivy Hospice Care.
To request an amendment, please submit your request in writing to the address written on the first page of this notice. This document should explain in detail the information you wish to have amended and the reason to support your request for amendment.
Ivy Hospice Care may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Ivy Hospice Care may deny your request if you ask Ivy Hospice Care to amend information that:
Was not created by Ivy Hospice Care;
Is not part of the medical information kept by or for Ivy Hospice Care;
Is not part of the information which you would be permitted to inspect and copy; or
Ivy Hospice Care believes the record is accurate and complete.
Right to Submit Addendum
If we deny your request to amend your medical record, you may submit a statement of disagreement or “addendum” to be added to your medical record indicating that you believe information in your medical record is incomplete or incorrect.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures” of information disclosed by Ivy Hospice Care in the six years prior to the date requested. To request this list or accounting of disclosures, please submit your written request to Ivy Hospice Care at the address listed on the first or last page of this Notice. The first accounting of disclosures you request within a 12-month period will be free. For additional lists, Ivy Hospice Care may charge you for the costs of providing you with the accounting.
Right to Request Restrictions
You have the right to request a restriction or limitation on the medical information Ivy Hospice Care uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Ivy Hospice Care discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you can ask that Ivy Hospice Care not use or disclose information about your terminal diagnosis or the basis of your hospice eligibility to a family member.
Ivy Hospice Care is not required to agree to your request. However, if Ivy Hospice Care does agree to your requested restriction, Ivy Hospice Care will comply with your request unless the information is needed to provide you emergency treatment.
You have the right to restrict disclosures of protected health information to a health plan if you have paid for these services in full out of your own pocket.
To request restrictions, please submit your request in writing to Ivy Hospice Care at the address printed on the first page of this notice. Only the Administrator of Ivy Hospice Care can approve this type of special restriction. In your request, you must tell Ivy Hospice Care:
What information you want to limit
Whether you want to limit Ivy Hospice Care’s use, disclosure or both; and to whom you want the limits to apply (for example, disclosures to your children).
Right to Request Confidential Communications
You have the right to request that Ivy Hospice Care communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Ivy Hospice Care only discuss your medical condition or information when specific individuals are out of the room.
To request these types of confidential communications, please submit your request in writing to Ivy Hospice Care at the address printed on the first page of this notice. Only the Administrator of Ivy Hospice Care can approve this type of special restriction. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice
You have the right to retain a copy of this notice. You may ask Ivy Hospice Care to give you a copy of this notice at any time. You may ask that Ivy Hospice Care provide you with a copy at the time you are first given the notice or you may call the contact person listed above at any later time to request such a copy.
CHANGES TO THIS NOTICE
Ivy Hospice Care reserves the right to change this notice. Ivy Hospice Care reserves the right to make the revised or changed notice effective for medical information we already have about you as well as any information we will receive in the future. Ivy Hospice Care will provide you with a revised version within a reasonable amount of time from the date of publication of the new rules. You may request a copy of this notice or an update of this notice at any time. The most up to date version of this notice will be made available at the Ivy Hospice Care Website, www.ivyhospicecare.com.
If you believe your privacy rights have been violated, you may file a complaint with Ivy Hospice Care or with the Secretary of the U.S. Department of Health and Human Services (DHHS). All complaints must be submitted in writing. You will not be penalized for filing a complaint.
To file a complaint with Ivy Hospice Care, write to:
Ivy Hospice Care
545 North Mountain Avenue, Suite 101
Upland, CA 91786
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to Ivy Hospice Care will be made only with your written permission. If you provide Ivy Hospice Care permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, Ivy Hospice Care will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that Ivy Hospice Care is not able to take back any disclosures Ivy Hospice Care has already made with your permission, and that Ivy Hospice Care is required to retain our records of the services that Ivy Hospice Care provided to you.
This notice is effective 06/22/2017
545 North Mountain Ave Ste 101, Upland, CA 91786 | firstname.lastname@example.org