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.

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

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

• Quality assessment and improvement activities. 
• 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 management and general administrative activities of Hospice.
• Fundraising for the benefit of Hospice.

For example, Hospice 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, 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, or contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).

For Hospice Inpatient Admissions. Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and your location in the Hospice unit while you are receiving inpatient care.  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 disclosed.

For Fundraising Activities.  Hospice 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 Hospice.  Hospice may also release this information to a related Hospice foundation.  If you do not want the Hospice to contact you or your family, notify the Privacy Officer 740-283-7487 or toll-free 877-467-7423 and indicate that you do not wish to be contacted. 

For Appointment Reminders.  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.  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. 

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.  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 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 Report Abuse, Neglect Or Domestic Violence.  Hospice is required to notify government authorities if  Hospice believes a patient is the victim of abuse, neglect or domestic violence.  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.  Hospice may disclose your health information to a health oversight entity for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action.  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.  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 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, 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 Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct at Hospice.
• In an emergency in order to report a crime.

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

For Organ, Eye Or Tissue Donation.  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.  Hospice may, under very select circumstances, use your health information for research project that will have been subject to an extensive approval process.

In the Event of A Serious Threat To Health Or Safety.  Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if 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 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.  

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than as stated above, Hospice will not disclose your health information other than with your written authorization.  If you or your representative authorizes 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 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 Hospice ‘s disclosure of your health information to someone who is involved in your care or payment for your care.  However, Hospice is not required to agree to your request.  If you wish to make a request for restrictions, please contact the Privacy Officer 740-859-5650 or toll-free 877-467-7423.

Right to receive confidential communications.  You have the right to request that Hospice communicate with you in a certain way.  For example, you may ask that 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 contact the Privacy Officer 740-283-7487 or toll-free 877-467-7423.Hospice will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.

Right to access 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 must be made in writing to the Privacy Officer 740-859-5650 or toll-free 877-467-7423.  You may contact the Privacy Officer for a request form.  If you request a copy of your health information, 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 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 Hospice.  A request for an amendment of records must be made in writing to Valley Hospice Privacy Officer, 10686 State Route 150, Rayland, Ohio 43943.  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 Hospice, if the records you are requesting are not part of 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 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 Hospice 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 Valley Hospice Privacy Officer, 10686 State Route 150, Rayland, Ohio 43943.  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 (6) years.  Hospice 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 the right to a separate paper copy of this Notice at any time even if a copy has been previously received.  To obtain a separate paper copy, please contact the Privacy Officer 740-859-5650 or toll-free 877-467-7423.

DUTIES OF HOSPICE

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.  Hospice is required to abide by the terms of this Notice as may be amended from time to time.  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 Hospice changes its Notice, you or your representative will receive a revised copy.

You or your personal representative have the right to express complaints to Hospice and to the Secretary of DHHS if you or your representative believe that your privacy rights have been violated.  Any complaints to Hospice should be made in writing to Valley Hospice Privacy Officer, 380 Summit Avenue, Steubenville, Ohio 43952.  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. 

Effective Date

This Notice is effective on April 14, 2003.

CONTACT PERSON

Hospice has designated the Privacy Officer as the contact person for all issues regarding patient privacy and your rights under the Federal privacy standards.  You may contact this person at:    

Valley Hospice Privacy Officer
10686 State Route 150, Rayland, Ohio 43943 
Local: 740-859-5650 
Toll free: 877-467-7423

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Nondiscrimination Policy

Valley Hospice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Valley Hospice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Valley Hospice:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages.

If you need these services, contact Toni Elliott. If you believe that Valley Hospice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Toni Elliott, Vice President of Quality Management, 10686 State Route 150, Rayland, Ohio 43943, Phone: 740-859-5650, Fax: 740-859-5697, telliott@valleyhospice.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Toni Elliott is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

 

Español (Spanish)

Valley Hospice cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexoValley Hospice no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.

Valley Hospice:

• Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes:
• Intérpretes de lenguaje de señas capacitados.
• Información escrita en otros formatos (letra grande, audio, formatos electrónicos       accesibles, otros formatos).
• Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:
  • Intérpretes capacitados.
  • Información escrita en otros idiomas.

Si necesita recibir estos servicios, comuníquese con Toni Elliott. Si considera que Valley Hospice no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Toni Elliott, Vice President of Quality Management, 10686 State Route 150, Rayland, Ohio 43943, Phone: 740-859-5650, Fax: 740-859-5697, telliott@valleyhospice.org. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Toni Elliott, Vice President of Quality Management está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,o bien, por correo postala la siguiente dirección o por teléfono a los números que figuran acontinuación:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

 

Deutsch (German)

Valley Hospice erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab. Valley Hospice lehnt den Ausschluss oder die unterschiedliche Behandlung von Menschen aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab.

Valley Hospice:

• Bietet kostenlose Hilfe und Dienstleistungen für Menschen mit Behinderung zur effektiven Kommunikation, wie z. B.:
  • Qualifizierte Gebärdensprachen-Dolmetscher
  • Schriftliche Informationen in anderen Formaten (große Ausdrucke, Audio, zugängliche elektronische Formate, sonstige Formate)
  • Bietet kostenlose Sprachdienste für Menschen, deren Hauptsprache nicht Englisch ist, wie z. B.:
    • Qualifizierte Dolmetscher
    • Schriftliche Informationen in anderen Sprachen

Sollten Sie diese Dienstleistungen benötigen, so wenden Sie sich an Toni Elliott.

Sollten Sie der Ansicht sein, dass Valley Hospice es versäumte, diese Dienstleistungen anzubieten, oder auf sonstige Weise aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht diskriminierte, so können Sie eine Beschwerde einreichen bei: Toni Elliott, Vice President of Quality Management, 10686 State Route 150, Rayland, Ohio 43943, Phone: 740-859-5650, Fax: 740-859-5697, telliott@valleyhospice.org. Sie können eine Beschwerde persönlich oder per Post, Fax oder E-Mail einreichen. Sollten Sie Hilfe beim Einreichen einer Beschwerde benötigen, so steht Ihnen Toni Elliott, Vice President of Quality Management gerne zur Verfügung.

Sie können ebenfalls eine Menschenrechtsbeschwerde einreichen bei: Department of Health and Human Services (U.S.-Gesundheitsministerium), Office for Civil Rights (Amt für Bürgerrechte), elektronisch über das Office for Civil Rights Complaint Portal, zugänglich über https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, oder per Post oder telefonisch an:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C., 20201

1-800-368-1019, 800-537-7697(TDD)

Beschwerdeformulare sind verfügbar unter http://www.hhs.gov/ocr/office/file/index.html.

 

Français (French)

Valley Hospice respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap. Valley Hospice n'exclut et ne traite aucune personne différemment en raison de sa race, sa couleur de peau, son origine nationale, son âge, son sexe ou son handicap.

Valley Hospice:

• Fournit gratuitement des aides et services aux personnes handicapées afin de permettre une communication efficace avec nous, par exemple :
• Interprètes qualifiés en langue des signes
• Informations écrites dans d'autres formats (gros caractères, audio, formats électroniques accessibles, autres formats)
• Fournit gratuitement des services linguistiques aux personnes dont la langue principale n'est pas l'anglais, par exemple :
  • Interprètes qualifiés
  • Informations écrites dans d'autres langues

Si vous avez besoin de ces services, contactez Toni Elliott.

Si vous pensez que Valley Hospice n'a pas fourni ces services ou a fait preuve d'une autre forme de discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou le handicap, vous pouvez déposer une réclamation auprès de : Toni Elliott, Vice President of Quality Management, 10686 State Route 150, Rayland, Ohio 43943, Phone: 740-859-5650, Fax: 740-859-5697, telliott@valleyhospice.org. Vous pouvez déposer une réclamation en personne ou par courrier, télécopie ou e-mail. Si vous avez besoin d'aide pour déposer une réclamation, Toni Elliott, Vice President of Quality Management] se tient à votre disposition pour vous y aider.

Vous pouvez également deposer une réclamation concernant vos droits civiques a uprès de l 'U.S. Department of Health and Human Services (Département d e la Santé et des Services Sociaux des États-Unis), Office for Civil Rights (Bureau d es Droits Civiques), par voie électronique via l'Office for Civil Rights Complaint Portal, disponible à l'adresse https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, par courrier ou par téléphone à:

U.S.Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C., 20201

1-800-368-1019, 800-537-7697 (TDD)

Des formulaires de réclamation sont disponibles à l'adresse http://www.hhs.gov/ocr/office/file/index.html

 

Italiano (Italian)

Valley Hospice è conforme a tutte le leggi federali vigenti in materia di diritti civili e non pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso. Valley Hospice non esclude le persone o le tratta diversamente a causa di razza, colore, origine nazionale, età, disabilità o sesso.

Valley Hospice

• Offre sostegni e servizi gratuiti alle persone affette da disabilità per comunicare con noi in modo efficace, quali:
• Interpreti qualificati nella lingua dei segni
• Informazioni scritte in altri formati (stampe a grandi caratteri, audio, formati elettronici accessibili, altri formati)
• Offre servizi linguistici gratuiti alle persone la cui lingua primaria non è l'inglese, quali:
  • Interpreti qualificati
  • Informazioni scritte in altre lingue

 In caso si necessiti di tali servizi, contattare Toni Elliott.

In caso si ritenga che Valley Hospice non abbia offerto tali servizi o abbia posto in essere discriminazioni in altri modi sulla base di razza, colore, origine nazionale, età, disabilità o sesso, è possibile presentare una vertenza a: Toni Elliott, Vice President of Quality Management, 10686 State Route 150, Rayland, Ohio 43943, Phone: 740-859-5650, Fax: 740-859-5697, telliott@valleyhospice.org.. È possibile presentare una vertenza di persona o a mezzo posta, fax oppure e-mail. In caso si necessiti di aiuto per la presentazione della vertenza, Toni Elliott, Vice President of Quality Management. è disponibile a fornire assistenza.

È altresì possibile presentare un reclamo per i diritti civili allo U.S. Department of Health and Human Services (Dipartimento statunitense per la salute e i servizi umani), Office for Civil Rights (Ufficio per i diritti civili), elettronicamente mediante il Office for Civil Rights Complaint Portal, disponibile all'indirizzo https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, oppure a mezzo posta o telefono a ll'attenzione di:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019,800-537-7697 (TDD)

I moduli di reclamo sono disponibili all'indirizzo http://www.hhs.gov/ocr/office/file/index.html.

 

繁體中文 (Chinese)

Valley Hospice 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。Valley Hospice 不因種族、膚色、民族血統、年齡、殘障或性別而排斥任何人或以不同的方式對待他們。

Valley Hospice:

• 向殘障人士免費提供各種援助和服務，以幫助他們與我們進行有效溝通，如：○合格的手語翻譯員
•  ä»¥å…¶ä»–格式提供的書面資訊（大號字體、音訊、無障礙電子格式、其他格式）
  • 向母語非英語的人員免費提供各種語言服務，如：
  • 合格的翻譯員
  • 以其他語言書寫的資訊如果您需

要此類服務，請聯絡 Toni Elliott.如果您認為Valley Hospice 未能提供此類服務或者因種族、膚色、民族血統、年齡、殘障或性別而透過其他方式歧視您，您可以向 Toni Elliott 提交投訴，郵寄地址為10686 State Route 150, Rayland, Ohio 43943，電話號碼為 740-859-5650、真為 740-859-5697，電子信箱為 telliott@valleyhospice.org 。您可以親自提交 投訴，或者以郵寄、傳真或電郵的方式提交投訴。如果您在提交投訴方面需要幫助，Toni Elliott, Vice President of Quality Management. 可以幫助您。

您還可以向U.S. Department of Health and Human Services（美國衛生及公共服務部）的Office for Civil Rights（民權辦公室）提交民權投訴，透過 Office for Civil Rights Complaint Portal 以電子方式投訴：https://ocrportal.hhs.gov/ocr/portal/lobby.jsf，或者透過郵寄或電話的方式投訴：

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C., 20201

1-800-368-1019，800-537-7697 (TDD)

 ï¼ˆè¾äººç”¨é›»ä¿¡è¨­å‚™ï¼‰ç™»å…¥ http://www.hhs.gov/ocr/office/file/index.html 可獲得投訴表格。

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