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.

USE AND DISCLOSURE OF HEALTH INFORMATION

High Peaks Hospice & Palliative Care (HPH&PC) 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.  High Peaks 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:

To Provide Treatment.  HPH&PC 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 HPH&PC interdisciplinary team and other health care professionals who have agreed to assist HPH&PC in coordinating care.  For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.  HPH&PC also may disclose your health care information to individuals outside of HPH&PC 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.  HPH&PC may include your health information in invoices to collect payment from third parties for the care you may receive from HPH&PC.  For example, High Peaks Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or HPH&PC.  HPH&PC 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.  HPH&PC may use and disclose health information for its own operations in order to facilitate the function of HPH&PC and as necessary to provide quality care to all HPH&PC patients.  Health care operations includes such activities as: 

• 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 analysis and formulary development.
   

• Business management and general administrative activities of High Peaks Hospice.
   

• Fundraising for the benefit of HPH&PC.

For example HPH&PC may use your health information to evaluate its staff performance, combine your health information with other HPH&PC patients in evaluating how to more effectively serve all HPH&PC patients, disclose your health information to HPH&PC 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 general fundraising and community information mailings (unless you tell us you do not want to be contacted).

For Fundraising Activities.  HPH&PC may use information about you including your name, address, phone number and the dates you received care in order to contact you or your family to raise money for HPH&PC. If you do not want High Peaks Hospice to contact you or your family, notify the Development Coordinator (891-0606 for the Tri-Lakes office, 743-1672 for the Glens Falls office), and indicate that you do not wish to be contacted. 

For Appointment Reminders.  HPH&PC may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit.

For Treatment Alternatives.  HPH&PC 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: 

When Legally Required.  HPH&PC 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.  HPH&PC may disclose your health information for public activities and purposes, without specifically identifying you, 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.
   

• 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.
   

• 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.  HPH&PC is allowed to notify government authorities if HPH&PC believes a patient is the victim of abuse, neglect or domestic violence. HPH&PC 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.  HPH&PC may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action.  HPH&PC, 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.  HPH&PC 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 HPH&PC 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 New York State law, High Peaks Hospice may disclose your health information to a law enforcement official for certain 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 HPH&PC has a suspicion that your death was the result of criminal conduct.
   

• In an emergency in order to report a crime.

To Coroners And Medical Examiners.  HPH&PC 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.  HPH&PC 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, High Peaks Hospice may disclose your health information prior to and in reasonable anticipation of your death.

For Organ, Eye Or Tissue Donation.  HPH&PC 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.  HPH&PC may, under very select circumstances, use your health information for research.  Before High Peaks 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.  HPH&PC may, consistent with applicable law and ethical standards of conduct, disclose your health information if it, 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 HPH&PC 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.  HPH&PC may release your health information for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, HPH&PC will not disclose your health information other than with your written authorization.  If you or your representative authorizes High Peaks 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 HPH&PC maintains:

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 HPH&PC's disclosure of your health information to someone who is involved in your care or the payment of your care.  However, HPH&PC is not required to agree to your request.  If you wish to make a request for restrictions, please contact the Privacy Officer (891-0606).

Right to receive confidential communications.  You have the right to request that HPH&PC communicate with you in a certain way.  For example, you may ask that HPH&PC 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 Privacy Officer (891-0606).  HPH&PC 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 Privacy Officer (891-0606).  If you request a copy of your health information, HPH&PC may charge a reasonable fee for copying and assembling costs associated with your request.

Right to amend health care information.  You or your representative have the right to request that HPH&PC 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 HPH&PC.  A request for an amendment of records must be made in writing to the Privacy Officer (891-0606).  HPH&PC 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 HPH&PC, if the records you are requesting are not part of HPH&PC’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 HPH&PC, 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 HPH&PC 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 Privacy Officer (891-0606).  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.  HPH&PC 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 have 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 (891-9631).

DUTIES OF THE HOSPICE
HPH&PC 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.  HPH&PC is required to abide by terms of this Notice as may be amended from time to time.  HPH&PC 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 HPH&PC changes its Notice, it 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 HPH&PC 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 HPH&PC should be made in writing to the Privacy Officer.  HPH&PC 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. 

EFFECTIVE DATE            This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE PRIVACY OFFICER AT

HIGH PEAKS HOSPICE & PALLIATIVE CARE, INC
PO BOX 840
SARANAC LAKE, NY 12983
(518-891-9631)