THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THE INFORMATION.
EFFECTIVE DATE: This Notice is effective April 14, 2003; updated June 3, 2013
USE AND DISCLOSURE OF HEALTH INFORMATION
Circle of Life may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed only after Circle of Life has obtained your written consent. Circle of Life has established a policy to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES AND PURPOSES YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT:
To Provide Treatment: Circle of Life may use your health information to coordinate care within Circle of Life and with others involved in your care, such as your attending physician, members of Circle of Life interdisciplinary team and other health care professionals who have agreed to assist Circle of Life in coordinating care. Circle of Life also may disclose your health care information to individuals outside of Circle of Life involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals that Circle of Life uses in order to coordinate your care.
To Obtain Payment: Circle of Life may include your health information in invoices to collect payment from third parties for the care you may receive from Circle of Life . For example, Circle of Life may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Circle of Life . Circle of Life 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.
Right to Restrict Certain Disclosures to Health Plans: Circle of Life honors requests by you to restrict disclosures to health plans for purposes of carrying out payment or healthcare operations if the disclosure is not otherwise required by law and the PHI relates solely to a health care item or service for which you, a family member, another person or other health plan has paid the covered entity out of pocket, in full.
Circle of Life is not obligated to notify downstream providers of your request for a restriction. You need to separately exercise this right with other providers. It is important to note that you may not exercise this right when Circle of Life is required by State or other law to submit a claim to a health plan for services provided to you and such law does not include an exception for individuals paying out-of-pocket.
To Conduct Health Care Operations: Circle of Life may use and disclose health care information for its own operations in order to facilitate the function of Circle of Life and as necessary to provide quality care to all of Circle of Life’s patients. Except in team meetings or scheduling of care, YOUR NAME WILL NOT BE USED. Health care operations include such activities as:
1. Quality assessment and improvement activities.
2. Professional review and performance evaluation.
3. Training programs including those in which students, trainees or practitioners in health care learn under supervision.
4. Accreditation, certification, licensing or credentialing activities.
5. Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
6. Business planning and development including cost management and planning related analyses and formulary development.
FEDERAL PRIVACY RULES ALLOW CIRCLE OF LIFE TO USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION, FOR A NUMBER OF REASONS, AS FOLLOWS:
When Legally Required. Circle of Life 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. Circle of Life may disclose your health information for public activities and purposes in order to:
1. 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.
2. To 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.
3. To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
4. To an employer about an individual who is a member of the workforce as legally required.
To Report Abuse, Neglect Or Domestic Violence: Circle of Life is allowed to notify government authorities if Circle of Life believes a patient is the victim of abuse, neglect, exploitation or domestic violence. Circle of Life 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: Circle of Life may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Circle of Life, 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: Circle of Life may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or in response to a subpoena, discovery request or other lawful process, but only when Circle of Life makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes: Circle of Life may disclose your health information to a law enforcement official for law enforcement purposes as follows:
1. As required by law for reporting of certain types of wounds or other physical injuries pursuant to court order, warrant, subpoena or summons or similar process.
2. For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
3. Under certain limited circumstances, when you are the victim of a crime.
4. To a law enforcement official if Circle of Life has a suspicion that your death was the result of criminal conduct including criminal conduct at Circle of Life.
5. In an emergency in order to report a crime.
To Coroners And Medical Examiners: Circle of Life may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as required.
To Funeral Directors:. Circle of Life may disclose your health information to funeral directors consistent with applicable law and to carry out their duties. If necessary to carry out their duties, Circle of Life may disclose your health information prior to and in reasonable anticipation, of your death.
For Organ, Eye Or Tissue Donation. Circle of Life 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 IF IT IS YOUR WISH TO BE AN ORGAN DONOR.
For Research Purposes: Circle of Life may, under very select circumstances, use your health information for research. Before Circle of Life discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Circle of Life will ask your permission if any researcher will be granted access to your individually identifiable health information.
In the Event of A Serious Threat To Health Or Safety. Circle of Life may, consistent with applicable law and ethical standards of conduct, disclose your health information if Circle of Life, 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 Circle of Life 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: Circle of Life may release your health information for worker’s compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, Circle of Life will not disclose your health information other than with your written authorization. If you or your representative authorizes Circle of Life 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
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 Circle of Life’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Circle of Life is not required to agree to your request. If you wish to make a request for restrictions, please contact the Compliance Officer.
Right to receive confidential communications:. You have the right to request that Circle of Life communicate with you in a certain way. For example, you may ask that Circle of Life 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 Compliance Officer. Circle of Life 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 Compliance Officer. If you request a copy of your health information, Circle of Life may charge a reasonable fee for copying and assembling costs associated with your request.
Right to designate an individual to receive your PHI: You have the right to request that Circle of Life provide a copy of your PHI directly to a designated individual. This right applies to both paper and electronic information. Any such request must be in writing, signed by you, and must clearly identify the designated recipient and where the information should be sent. Circle of Life will provide reasonable verification procedures to verify the identity and authority of the requesting individual prior to disclosing any information.
Electronic Access: You have the right to obtain an electronic copy of your PHI. If the requested format is not available, then a mutually agreed upon format (e.g., Microsoft Word or Excel, text-based PDF) will be provided. Circle of Life is not required to provide you with unlimited choices in terms of the available electronic forms. If requested by you, Circle of Life may provide the electronic copy of PHI through unencrypted e-mail after Circle of Life has advised you of the risk of doing so. In such a case, Circle of Life would not be responsible for any unauthorized access of PHI while in transmission or for safeguarding PHI once delivered to you. Circle of Life may charge a reasonable fee for copying and assembling costs associated with your request. Circle of Life will provide access to all paper and electronic PHI within 30 days of your request, with the option of a one-time 30-day extension if needed.
Right to amend health care information: If you or your representative believes that your health information records are incorrect or incomplete, you may request that Circle of Life amend the records. A request for an amendment of records must be made in writing to the Circle of Life Compliance Officer. Circle of Life may deny the request if it is not in writing, does not include a reason for the amendment, if your health information records were not created by Circle of Life, if the records you are requesting are not part of Circle of Life’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 Circle of Life, 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 Circle of Life for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Circle of Life Compliance Officer. Accounting requests may not be made for periods of time in excess of six years. Circle of Life 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 has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously.
Right to complain if your privacy is violated: You or your personal representative has the right to express complaints to Circle of Life and to the Secretary of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to Circle of Life should be made in writing to the Circle of Life Compliance Officer. Circle of Life 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.
DUTIES OF PALLIATIVE CARE ASSOCIATES
Circle of Life 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. Circle of Life is required to abide by terms of this Notice as may be amended from time to time. Circle of Life 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 Circle of Life changes its Notice, Palliative Care Associates will provide a copy of the revised Notice to you or your appointed representative.
Circle of Life’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Compliance Manager, 901 Jones Road, Springdale, AR 72762