“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.”

This notice is effective April 14, 2003.

Our Agency is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information.  Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you.

As our patient, information about you may be used and disclosed to other parties for purposes of treatment, payment and health care operations.  Examples of information that may be disclosed:

·        Treatment: We may use information about you when we provide, coordinate or manage your health care and related services.  We may disclose information about you to doctors, nurses, hospitals and other health care providers involved in your care. We may consult with other health care providers concerning you and as part of the consultation, share your information with them.  

·        Payment: We may use or disclose information about you so we can be paid for the services we provide to you.  This can include billing you, your insurance company, or a third party payer. For example, we may need to provide information to your insurance company about the health care services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have paid.  We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your medical condition and the health care you need to receive in order to determine if you are covered by that insurance or program.

·        Health Care Operations: We may use and disclose information about you for our own health care operations.  This is necessary to operate VNA and to maintain quality health care for our clients.  For example, we may use information about you to review the services we provide and the performance of our employees in caring for you.  We may disclose information about you to train our staff, volunteers and students working in VNA.  We may also use the information to study ways to more efficiently manage our organization.

Federal law also allows us to use and disclose your information in the following ways:

Appointment/Visit Reminders: Unless you tell us otherwise, we may contact you by either telephone or by mail at either your home or an alternative location.  At either location, we may leave messages for you on the answering machine or voice mail.

Treatment Alternatives/Health Related Benefits and Services: We may use and disclose medical information about you to contact you about treatment alternatives or health related benefits and services  that may be of interest to you.

Fundraising:  We may use your demographic information to raise funds for VNA.  If you do not want VNA or its Foundation to contact you for fundraising, you must notify VNA in writing.  We will not share your information with any entity for fundraising or marketing purposes.

Required by Law:  We may use or disclose medical information about you when we are required to do so by law.

Public Health Activities:  We may disclose medical information about you for public health activities and purposes.  This includes reporting medical information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. 

Victims of Abuse, Neglect or Domestic Violence: We may disclose medical information about you to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence.  We will only make this disclosure if you agree or if we are required or authorized to do so by law.

Health Oversight Activities:  We may disclose medical information about you to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings:  We may disclose medical information about you in response to a subpoena, court order, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.

Disclosures for Law Enforcement Purposes:  We may disclose medical information about you to a law enforcement official for law enforcement purposes: such as responding to a subpoena or court order, or to notify authorities of a criminal act.

Coroners, Medical Examiners and Funeral Directors:  We may disclose medical information about you to a coroner, medical examiner for purposes such as identifying a deceased person and determining cause of death.  We may disclose medical information about you to funeral directors as necessary for them to carry out their duties.

Organ, Eye and Tissue Donation: We may disclose medical information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue as necessary to facilitate organ, eye or tissue donation or transplantation.

To Avert a Serious Threat to Health or Safety:  We may use and disclose medical information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Disclosures, however, will only be made to an individual or entity who may be able to help prevent the threat.

National Security and Military Functions: We may disclose medical information regarding you including military and veteran activities, national security and intelligence activities, protective services for the president and others, correctional institutions and custodial situations.

Workers Compensation: We may disclose medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.

Disaster Relief:  We may use or disclose medical information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. 

Facility Directory:  We may include your name in a list of current clients served at our Hospice Center in a facility directory when applicable.  We are permitted to disclose your location at the facility and condition described in general terms to an individual who asks for you by name.  We are further permitted to disclose this information to clergy along with your religious affiliation.  You may request that this information not be disclosed by notifying your nurse.

Individuals Involved in Your Care:  We may disclose to a family member, other relative, a close personal friend, or any other person identified by you, information about you that is directly relevant to that person’s involvement with your care or payment related to your care.  You may request that information not be disclosed to a particular person by submitting your request in writing to the Privacy Officer.

Other uses and disclosures of information will be made only with your written authorization:  That authorization may be revoked, in writing, at any time.  However, should you revoke such an authorization, you should understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records as proof of the care that we provided you.

YOUR RIGHTS - All requests should be submitted in writing to the Privacy Officer.  You have the right, subject to certain conditions, to the following:

·        Right to request restrictions on certain uses and disclosures of information about you. You have the right to request that we restrict the uses or disclosures of medical information about you to carry out treatment, payment, or health care operations.  You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) public or private entities for disaster relief efforts.  For example, you could ask that we not disclose medical information about you to your brother or sister.  We are not required to agree to any requested restriction.  However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment.  Even if we agree to a restriction, either you or we can later terminate the restriction.

·        Right to receive confidential communication of protected health information . For example, you can ask that we only contact you by mail or at an alternate location.  We will not require you to tell us why you are asking for the confidential communication. 

·        Right to inspect and copy protected health information. With a few very limited exceptions, you have the right to inspect and obtain a copy of medical information about you. Your written request should state specifically what medical information you want to inspect or copy.  We will act on your request no later than 30 days after our receipt of the request.  If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.

·        Request to amend protected health information for as long as the protected health information is maintained in the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within sixty (60) days of receipt of the request.  We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request.

·        Right to receive an accounting of disclosures for reasons other than treatment, payment, health care operations and certain other activities for the last 6 years, but not prior to April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost based fee for responding to these additional requests.

COMPLAINTS - If you believe that your privacy rights have been violated, you may complain to VNA or to the Secretary of the U.S. Department of Health and Human Services, Washington, D.C. There will be no retaliation against you for filing a complaint.  

The complaint should be filed in writing with VNA and should state the specific incidents(s) in terms of subject, date, and other relevant matters.  Complaints should be directed to:  VNA Privacy Officer, 501 Marquette Street, Valparaiso, IN, 46383.  A complaint to the Secretary must comply with the standards set out in 45 CFR § 160.306.  

OUR DUTIES - We are required to abide by the terms of our Notice of Privacy Practices in effect at the time. We reserve the right to change this Notice of Privacy Practices and to make the new notice’s provisions effective for all medical information that we maintain, including that created or received by us prior to the  effective date of the new notice.  VNA will provide you a copy of a written revised notice upon request.

If you have any questions or want more information concerning this Notice of Privacy Practices, or wish to request a copy of this notice, please contact the

VNA Privacy Officer at (219) 462-5195.