Hospice Training Guide

NOTICE OF PRIVACY PRACTICES

H. For Organ, Eye or Tissue Donation: Four Seasons 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 trans- plantation. I. For Research Purposes: Four Seasons may, under very select circumstances, use your health information for research. Before Four Seasons discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Four Sea- sons will ask your permission before any researcher will be granted access to your individually identifiable health information. J. In the Event of a Serious Threat to Health or Safety: Four Seasons may, consistent with appli- cable law and ethical standards of conduct, disclose your health information if Four Seasons, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and im- minent threat to your health or safety or to the health and safety of the public. K. For Specified Government Functions: In certain circumstances, the Federal regulations author- ize Four Seasons to use or disclose your health information to facilitate specified government functions relating to military personnel and veterans, national security and intelligence activi- ties, protective services for the President and others, medical suitability determinations, and inmates and law enforcement custody. L. For Worker’s Compensation: Four Seasons may release your health information for Worker’s Compensation or similar programs. IV. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than as stated above, Four Seasons will not disclose your health information without your written authorization. If you or your representative authorizes Four Seasons to use or disclose your health information, you may revoke that authorization in writing at any time, except to the extent that Four Seasons has already acted upon your authorization. Four Seasons will obtain your authorization prior to: (a) disclosing your Psychotherapy Notes, if applicable; (b) using your health information for most marketing communications, except face-to-face communications, whenever Four Seasons is paid by a third party for making such communications; or (c) disclosing your health information in a manner which constitutes the sale of such information under the Health Informa- tion Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations. V. YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information maintained by Four Seasons: A. Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information. For example, you may request a limit on Four Seasons’ disclosure of your health information to someone who is involved in your care or the payment of your care. All requests for restrictions must be made in writing using the appropriate Four Seasons form. Except in limited circumstances, Four Seasons is not required to agree to your request. Except as otherwise required by law, Four Seasons must agree to a restriction request if: (i) the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and (ii) the health information pertains solely to a health care item or service for which you, or another person other than the

• 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. C. To Report Abuse, Neglect or Domestic Violence: Four Seasons may disclose your health infor- mation to government authorities if we believe you are the victim of abuse, neglect or domestic violence. Four Seasons 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: Four Seasons may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investi- gations, inspections, licensure or disciplinary action. Four Seasons may not, however, 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. Four Seasons may dis- close your health information to the North Carolina Department of Health Service Regulation to validate Four Seasons’ compliance with North Carolina law. You have the right to object to a disclosure of your health information to the North Carolina Department of Health Service Regulation for this purpose. Such objections shall be made in writing on your Consent for Hos- pice Care upon admission or to the Four Seasons Privacy Officer at the address listed in Section VI below. D. In Connection With Judicial and Administrative Proceedings: Four Seasons 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 Four Seasons makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information. E. For Law Enforcement Purposes: Four Seasons may disclose your health information to a law enforcement official for law enforcement purposes as follows: • As required by law for reporting 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 Four Seasons has a suspicion that your death was the result of criminal conduct including criminal conduct at Four Seasons; or • In an emergency in order to report a crime. F. To Coroners and Medical Examiners: Four Seasons 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. G. To Funeral Directors: Four Seasons 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, Four Seasons may disclose your health information prior to and in reasonable anticipation of your death.

866.466.9734

FourSeasonsCare.org

866.466.9734

Four Seasons

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