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BIG BEND HOSPICE NOTICE OF PRIVACY PRACTICES

Big Bend Hospice takes the privacy of your health information seriously. The Hospice is required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. 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.


USES AND DISCLOSURES OF HEALTH INFORMATION

Big Bend Hospice (BBH) may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed for other purposes only after BBH has obtained your written authorization. BBH has established a policy to guard against unnecessary disclosure of your health information and does not sell health information.

THE FOLLOWING IS A SUMMARY OF CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. BBH may use your health information to coordinate care within BBH and with others involved in your care, such as your attending physician, members of BBH interdisciplinary team and other health care professionals who have agreed to assist BBH in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. BBH also may disclose your health care information to individuals outside of BBH involved in your care including, pharmacists, suppliers of medical equipment or other health care professionals that BBH uses in order to coordinate your care. With your authorization, BBH may also disclose information about your care to family members or clergy for whom you have provided written authorization.

To Obtain Payment. BBH may include your health information in invoices to collect payment from third parties for the care you may receive from BBH. For example, BBH may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or BBH. BBH 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. BBH may use and disclose health care information for its own operations in order to facilitate the function of BBH and as necessary to provide quality care to all of BBH's patients. Health care operations includes such activities as:

• To meet legally required health care information reporting requirements
• 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 BBH.
• Fundraising for the benefit of BBH and certain marketing activities.

For example BBH 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 or report legally required information to a state or federal agency, to 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, and community information mailings (unless you tell us you do not want to be contacted). BBH will not release all or any part of its mailing list to any outside organization or individual. BBH does not market healthrelated
products or services to patients nor will BBH give PHI to a telemarketer, door-to-door salesperson, or other marketer it may hire.

BBH may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in BBH facility in a Hospice directory while you are in BBH inpatient facility. BBH may disclose this information to people who ask for you by name. Please inform us if you do not want your information to be included in the directory.

For Fundraising Activities. BBH may use information about you including your name, address, phone number and the dates you received care at BBH in order to contact you or your family to raise money for BBH. If you do not want BBH to contact you or your family, notify the Compliance Officer and indicate that you do not wish to be contacted. In no event will BBH sell patients’ personal health information and such practice requires an authorization from you in advance.

Federal privacy rules allow or require BBH to use or disclose your health information without your consent or authorization for a number of reasons:

When Legally Required. BBH 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. BBH 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.
• To 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.
• To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
• To an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence. BBH is allowed to notify government authorities if BBH believes a patient is the victim of abuse, neglect or domestic violence. BBH 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. BBH may disclose your health information to a health
oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. BBH, 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. BBH may disclose your health
information in the course of any judicial or administrative proceeding in response to an order of a court as expressly authorized by such order.

For Law Enforcement Purposes. BBH may disclose your health information to a law enforcement official for 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 a law enforcement official if BBH has a suspicion that your death was the result of criminal conduct including criminal conduct at BBH.
• In an emergency in order to report a crime.

To Coroners And Medical Examiners. BBH 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. BBH 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, BBH may disclose your health information prior to and in reasonable anticipation, of your death.

For Organ, Eye Or Tissue Donation. BBH 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. BBH may, under very select circumstances, use your health information for research. Before BBH discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. BBH will ask your permission if any researcher will be granted access to your individually identifiable health information.

In the Event of A Serious Threat To Health Or Safety. BBH may, consistent with applicable law and ethical standards of conduct, disclose your health information if BBH, 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 BBH 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. BBH may release your health information for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated above, BBH will not disclose your health information other than with your written express authorization. If you or your representative authorizes BBH 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 BBH maintains:

• Right to request restrictions. You have the right to request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on BBH’s disclosure of your health information to someone who is involved in your care or the payment of your care. BBH is not required to agree to your request, unless your request is for a restriction on a disclosure to a health plan for purposes of payment or health care operations (and is not for purposes of treatment) and the medical information you are requesting to be restricted from disclosure pertains solely to a health care item or service for which you have paid out of pocket in full. If you wish to make a request for restrictions, please contact the Compliance Officer.

• Right to receive confidential communications. You have the right to request that BBH communicate with you in a certain way. For example, you may ask that BBH 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. BBH 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 the Compliance Officer. If you request a copy of your health information, BBH may charge a reasonable fee for copying and assembling costs associated with your request. You have the right to request that BBH provide you, an entity or a designated individual with an electronic copy of your electronic health record containing your health information. BBH may require you to pay the labor costs incurred by the Hospice in responding to your request.

• Right to amend health care information. If you or your representative believes that your health information records are incorrect or incomplete, you may request that BBH amend the records. That request may be made as long as the information is maintained by BBH. A request for an amendment of records must be made in writing to the Compliance Officer. BBH 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 BBH, if the records you are requesting are not part of BBH'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 BBH, 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 BBH for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Compliance Officer. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. BBH 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 paper copy of this Notice at any time even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact the Compliance Officer. Anyone may also obtain a copy of the current version of BBH's Notice of Privacy Practices at its website, www.bigbendhospice.org.

• In the event of a Breach of Health Information. BBH is required to timely notify you in the event of a breach that poses a significant risk of financial, reputation or other harm to you. Any such notification will include a description of what happened, the types of information involved in the breach, steps we have taken and will take to mitigate any potentially harmful effects of the breach and further information for you on how to protect yourself following the breach. In addition, you will be informed of contact information such as a toll free number phone number to call or e-mail and internet or postal address for you to receive further information.

DUTIES OF Big Bend Hospice

BBH 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. BBH is required to abide by terms of this Notice as may be amended from time to time. BBH 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 BBH changes its Notice, BBH 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 BBH and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to BBH should be made in writing to the Compliance Officer. BBH 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.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
the Compliance Officer of Big Bend Hospice.

CONTACT PERSON

BBH's contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is:

Mary Zenere, Compliance Officer
Big Bend Hospice
1723 Mahan Center Blvd
Tallahassee, FL 32308
(850) 878-5310 ext 139

EFFECTIVE DATE
This Notice is effective September 23, 2013.

1723 Mahan Center Blvd. • Tallahassee, FL 32308 • 850.878.5310 or 800.772.5862