Privacy Practices

Use and Disclosure of Health Information

Avow Hospice, Inc. (Avow 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. Avow 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 AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT.

To Provide Treatment

Avow Hospice may use your health information to coordinate care within Avow Hospice and with others involved in your care, such as your attending physician, members of Avow Hospice interdisciplinary team and other health care professionals who have agreed to assist Avow Hospice in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Avow Hospice also may disclose your health care information to individuals outside of Avow Hospice involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals that Avow Hospice uses in order to coordinate your care.

To Obtain Payment

Avow Hospice may include your health information in invoices to collect payment from third parties for the care you may receive from Avow Hospice. For example, Avow Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Avow Hospice. Avow 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

Avow Hospice may use and disclose health care information for its own operations in order to facilitate the function of Avow Hospice and as necessary to provide quality care to all of Avow Hospice's patients. Health care operations include, but are not limited to, 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 analyses and formulary development.
• Business management and general administrative activities of Avow Hospice.
• Fundraising for the benefit of Avow Hospice and certain marketing activities.

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

Avow Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in the Avow Hospice facility while you are in the Avow Hospice inpatient facility and listed in the directory. Avow Hospice 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

Avow Hospice engages in fundraising activities, the money from which is used to help support the mission of the organization. Avow Hospice may contact you asking you to consider giving a charitable gift. If you do not wish to receive fundraising communications, notify our Development Office at (239)261-4404 and ask to be removed from our mailing list.

For Appointment Reminders

Avow Hospice 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

Avow Hospice 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

Avow 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

Avow Hospice 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.
• Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
• Notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence

Avow Hospice is allowed to notify government authorities if Avow Hospice believes a patient is the victim of abuse, neglect or domestic violence. Avow 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

Avow 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. Avow 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

Avow Hospice may disclose your health information in the course of any judicial or administrative proceeding. Patient records or any portion thereof may not be released unless: a patient or legal guardian has given express written consent; a court of competent jurisdiction has so ordered; or a state or federal agency, acting under its statutory authority, requires submission of aggregate statistical data. For a deceased patient, records will only be released in response to a court order or subpoena.

For Law Enforcement Purposes

Avow Hospice 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 Avow Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct at Avow Hospice.
• In an emergency in order to report a crime.

To Coroners And Medical Examiners

Avow 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

Avow 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, Avow Hospice may disclose your health information prior to and in reasonable anticipation, of your death.

For Organ, Eye Or Tissue Donation

Avow 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

Avow Hospice may, under very select circumstances, use your health information for research. Before Avow 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

Avow Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if Avow 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 Avow 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

Avow Hospice may release your health information for worker's compensation or similar programs

Authorization to Use or Disclose Health Information

Other than is stated above, Avow Hospice will not disclose your health information other than with your written authorization. If you or your representative authorizes Avow 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 Avow Hospice 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 Avow Hospice disclosure of your health information to someone who is involved in your care or the payment of your care. However, Avow Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Official.
• Right to receive confidential communications You have the right to request that Avow Hospice communicate with you in a certain way. For example, you may ask that Avow Hospice 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 submit a written request to a member of the interdisciplinary team. Avow Hospice will not request that you provide any reasons for your request and will attempt to Avow Hospice or your reasonable requests for confidential communications.
• Right to inspect and obtain copies of 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 Health Information Management Department. If you request a copy of your health information, Avow Hospice 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 Avow Hospice 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 Avow Hospice. A request for an amendment of records must be made in writing to the Health Information Management Department. Avow Hospice 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 Avow Hospice, if the records you are requesting are not part of Avow Hospice'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 Avow Hospice, 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 Avow Hospice for certain reasons other than for treatment, payment or health operations and others exempted by law. The request for an accounting must be made in writing to the Privacy Official. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. Avow Hospice would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests are 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 have received this Notice previously. To obtain a separate paper copy, please contact the Privacy Official.

Duties of the Hospice

Avow 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. Avow Hospice is required to abide by terms of this Notice as may be amended from time to time. Avow 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 Avow Hospice changes its Notice, Avow Hospice will provide a copy of the revised Notice to you or your appointed representative upon request. Avow Hospice encourages you to express your concerns regarding the privacy of your information. If you or your representative believe that your privacy rights have been violated, you have the right to submit a written complaint to Avow Hospice's Privacy Official. You will not be retaliated against in any way for filing a complaint. You also have the right to express a complaint to the Secretary of the Department of Health & Human Services.

Contact Person

Avow Hospice has designated the Privacy Official as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at (239) 261-4404.

Effective Date

This Notice is effective October 26, 2007.