Hospice Training Guide

NOTICE OF PRIVACY PRACTICES

health plan on your behalf, has paid Four Seasons in full. This restriction will apply only to those health care records created on the date that you received the item or service for which you, or another person other than the health plan on your behalf, paid Four Seasons in full, and which document the item or service provided by Four Seasons on such date. B. Right to Request Confidential Communications: You have the right to request that Four Sea- sons communicate with you in a certain way. For example, you may ask that Four Seasons only conduct communications pertaining to your health information with you privately and with no other family members present. All requests for confidential communications must be made in writing using the appropriate Four Seasons form. Four Seasons will not request that you provide any reason(s) for your request and will attempt to honor your reasonable requests for confidential communications. C. Right to Inspect and Copy Your Health Information: You have the right to inspect and copy your health information, including billing records. All requests to inspect and copy health in- formation must be made in writing using the appropriate Four Seasons form. If you request a copy of your health information, Four Seasons may charge a reasonable fee for copying and assembling costs associated with your request. In limited circumstances, Four Seasons may deny your request to inspect and copy your health information; however, you may request a review of the denial by a licensed health care professional who Four Seasons has designated as a reviewing official and who did not participate in the original decision to deny the request. D. Right to Request Amendment of Your Health Information: If you believe that your health in - formation records are incorrect or incomplete, you have the right to request that Four Seasons amend the records. That request may be made as long as the information is maintained by Four Seasons. A request for an amendment of records must be made in writing using the appropri- ate Four Seasons form, and must contain a reason to support the requested amendment. The request may be denied if your health information records were not created by Four Seasons, if the records you are requesting are not part of Four Seasons’ records, if the health information you wish to amend is not part of the health information you or your representative are permit- ted to inspect and copy, or if, in the opinion of Four Seasons, the records containing your health information are accurate and complete. E. Right to Request an Accounting of Disclosures: You have the right to request an accounting of disclosures of your health information made by Four Seasons for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writ- ing on the appropriate Four Seasons form. 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. Four Seasons will 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. F. Right to a Paper Copy of this Notice: You have the right to a separate paper copy of this notice at any time even if you have received this notice previously. A copy of the current version of the Four Seasons Notice of Privacy Practices is also available at our website, FourSeasonsCare.org

G. Right to Receive Breach Notification: You have the right to receive notice of a breach of your unsecured health information. This notification may be delayed or not provided if so required by a law enforcement official. You may request that this notice be provided by electronic mail. If you are deceased and there is a breach of your health information, the notice will be pro- vided to your next of kin or personal representative if we know the identify and address of such individual(s). VI. QUESTIONS OR COMPLAINTS For all issues or questions regarding patient privacy and your rights under the Federal Privacy Standards, including requests for or complaints about your rights, you may contact: Melody King, Director of Compliance and/or Dr. Millicent Burke-Sinclair, President/CEO You, or your representative, have the right to express complaints to the Privacy Officer or Presi- dent/CEO of Four Seasons and to the Secretary of Health and Human Services if you, or your rep- resentative, believe that your privacy rights have been violated. Any complaints to Four Seasons should be made in writing to the Privacy Officer or President/CEO. We encourage 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 complaints regarding your privacy rights are not resolved satisfactorily, you may notify: Secretary of Health and Human Services 200 Independence Ave. SW 571 South Allen Rd Flat Rock, NC 28731 828.692.6178

Washington DC 20201 (877) 696.6775 (Toll Free)

VII. EFFECTIVE DATE This notice is effective 9/23/2013.

866.466.9734

FourSeasonsCare.org

866.466.9734

Four Seasons

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