Hospice Care of Southwest Michigan ["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 care operations. The Hospice has established policies to guard against unnecessary disclosure of your health information.

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, clergy whom you have designated, 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 care 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 clients. Health care operations includes such activities as:

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:

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 is 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:

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 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.

For Worker's Compensation. The Hospice may release your health information for worker's compensation or similar programs.

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.

You have the following rights regarding your health information that the Hospice maintains:

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 its Notice, the Hospice will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative have the right to express complaints to the Hospice and to the Secretary of the Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to the Hospice should be made in writing to the Chief Operating Officer.  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.

The Hospice has designated the Director of Quality and Compliance as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at Hospice Care of Southwest Michigan, Chief Operating Officer, 222 North Kalamazoo Mall, Suite 100, Kalamazoo, MI 49007; (269) 345-0273.

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT: