(Hospice of Texarkana, Inc. will be referred to as HOT throughout this Notice)

To Provide Treatment: HOT may use your health information to coordinate care within HOT and with others involved in your care, such as your attending physician, members of the Hospice interdisciplinary team and other health care professionals who have agreed to assist HOT in coordinating care.

To Obtain Payment: HOT may include your health information on bills sent to collect payment from third parties for the care you receive from HOT. For example, HOT will need to provide information about your health status so that the insurer will pay for services provided.

To Conduct Health Operations: HOT may use and disclose health care information for its own operations in order to facilitate the function of HOT and as necessary to provide quality care to all of the Hospice's patients. For example, HOT may use your health information to evaluate staff performance, or combine your health information with other Hospice patients in evaluating how to serve all HOT patients more effectively. Your health information may also be used or disclosed for accreditation, certification, licensing or credentialing activities.

Appointment Reminders: HOT may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit.

For Financial Support: HOT may use information about you, specifically: your name, address, and the dates you received care at HOT in order to contact you or your family by mail for any fundraiser activities. If you do not want HOT to contact you or your family, notify HOT and indicate that you do not wish to be contacted.

Use Or Disclosure Without Authorization: HOT will only use or disclose your health information without your consent or authorization when legally required to do so. For example, when there are risks to public health, to report abuse, neglect or domestic violence, for law enforcement purposes, to conduct oversight activities including audits and investigations, or for funeral arrangements.

Authorization To Use Or Disclose Health Information: Other than as stated above, HOT will not disclose your health information without your written authorization. If you or your representative authorizes HOT to use or disclose your health information, you may revoke that authorization in writing at any time.

You have the following rights regarding your health information that HOT maintains:

Right To Request Restrictions: You may request restrictions on certain uses and disclosures of your health information. However, HOT is not required to agree to your request. If you wish to make a request for restrictions, please contact HOT to submit a written request.

Right To Receive Confidential Communications: You have the right to request that HOT communicate with you in a certain way. For example, you may ask that HOT 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 HOT.

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 HOT. If you request a copy of your health information, HOT may charge a reasonable fee for copying and assembling costs associated with your request.

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 HOT amend the records. That request may be made as long as the information is maintained by HOT. A request for an amendment of records must be made in writing to HOT.

Right To An Accounting: You or your representative have the right to request an accounting of disclosures of your health information made by HOT for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to HOT.

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. To obtain a separate paper copy, please contact HOT. This Notice is also available for print by clicking on the icon at the top of this page.

DUTIES OF THE HOSPICE: HOT is required by law to maintain the privacy of your health information and to provide to you or your representative this Notice of its duties and privacy practices. HOT is required to abide by terms of this Notice. HOT 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 HOT changes its Notice, a revised copy and revision notice will be provided to your or your appointed representative by mail or delivered by your nurse. You or your personal representative has the right to express complaints to HOT 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 HOT should be made in writing to HOT Privacy Official. HOT encourages you to express any concerns you may have regarding the privacy of your health information. You and/or your representative will not be retaliated against in any way for filing a complain.

CONTACT PERSON: The HOT contact person for all issues regarding patient privacy and your right under the Federal Privacy Standards is Cindy Marsh, Executive Director, 2407 Galleria Oaks Dr., Texarkana, Texas 75503. Additionally contact may be made by any of the following means: 903-794-4263 (phone), 430-200-4677 (fax). Ms. Marsh may be contacted via telephone Monday-Friday 8:00 a.m. to 5:00 p.m.

EFFECTIVE DATE: This Notice is effective April 14, 2003.



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