Privacy Practices

This notice describes how medical information about you or your loved one may be used and disclosed and how you may access this information.  Please review it carefully.  If you have any questions about this Notice, please contact our Administration at 337-639-9200.
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law.  It also describes your rights with respect to your PHI.
 
Definition:  “Protected Health Information (PHI)” is medical information including demographic information, that may identify you and that relates to your past, present, or future physical or mental health and related healthcare services.
 
OUR RESPONSIBILITIES
Brighton Bridge Hospice takes the privacy of your health information seriously.  We are required by law to maintain the privacy and to provide you with this Notice of Privacy Practices.  This Notice is provided to tell you about our duties and practices with respect to your information.  We are required to abide by the terms of this Notice as are currently in effect.
 
USES AND DISCLOSURES OF PROECTED HEALTH IFORMATION FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS AND HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
 
The following are examples of the types of uses and disclosures of your PHI that Brighton Bridge Hospice is permitted by the Hipaa/Hi-tech Privacy Regulations to make for the purposes of treatment, payment, and healthcare operations.  These examples are not meant to be exhaustive, but only to give examples of the types of uses and disclosures that may be made by our office for these purposes.    The following categories describe different ways that Hospice uses and discloses your health information.  For each category, an explanation of the category is provided, in some cases with examples.  Not every use of disclosure in a category will be listed.  However, all of the ways Hospice is permitted to use and disclose your health information will fall into one of these categories.

TREATMENT:
We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services.  This includes the coordination or management of your healthcare with a third party such as another physician’s office.  For example, we may disclose your PHI, as necessary, to a home health agency that provides care to you.  We may also disclose PHI to your primary physician and/or to other physicians who may be treating you.  Your PHI also may be provided to a physician to whom you have been referred, to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your PHI to another healthcare provider (e.g., a specialist, laboratory, supplier of medical equipment or other healthcare professionals) who, at the request of your physician, becomes involved in your care by providing assistance with your treatment, as well as your primary caregiver.

PAYMENT:
Your PHI may be used, as needed, to obtain payment for healthcare services that we provide to you.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your PHI be disclosed to the health plan to obtain approval for the hospital admission. 
 
HEALTHCARE OPERATIONS:
We may use or disclose your PHI in order to support the business activities of our practice.  The activities include but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing, fundraising activities, and conducting or arranging for other business activities.  For example, we may disclose your PHI to medical students that see patients for training purposes.  We may also use PHI for quality assessment and performance improvement activities, activities designed to improve health or reduce healthcare costs, protocol development, case management and care coordination, contacting healthcare providers and patients with information about treatment alternatives and other related functions that do not include treatment,  professional review and performance evaluation of staff or other associates, training programs; including those in which trainees or practitioners in healthcare learn under supervision, training of non-healthcare professionals, accreditation, certification, licensing, or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and compliance programs, business planning and development, including cost management and planning related analyses and formulary development, business management and general administrative activities of Hospice: and last but not least fundraising for the benefit of the programs of Hospice.  For example, Hospice may use your PHI to evaluate its performance, combine your health information with other Hospice patients in evaluating how to more effectively serve all Hospice patients, disclose your PHI to members of the Hospice workforce for training purposes, use your health information to contact you as a reminder regarding a visit to you, or contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).  Any individual has the right to opt out of fundraising communications.
 
Other uses and disclosures of your PHI:
We may also use and disclose your PHI in the following ways:
 
Business Associates:  We may share your PHI with third party “business associates” that preform various activities (e.g., billing, transcription services) for the practice.  Whenever an arrangement between our office and a business associate involves the use of disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
 
Appointment Reminders and Other Information:  We may use your PHI to provide appointment reminders or information about treatment alternatives or health-related benefits and services that may be of interest to you.  For example, we may send you a newsletter about the practice or services that we offer.

Facility Directory:  We may disclose certain information about you, including your name, your general health status, your religious affiliation and where you are in the Hospice’s facility, in a Hospice directory if you are in a Hospice inpatient facility.  We may disclose this information to people who ask for you by name.  Please inform us if you do not want your information to be included in the directory. 

Fundraising Activities:  We may use information about you, including your name, address, telephone number and the dates you received care, in order to contact you for a fundraiser for programs of the Hospice.  We may also release this information to a related Hospice foundation.  If you do not want the Hospice to contact you, you may opt out by notifying Maureen Smith, Administrator at (337)639-9200 and indicate that you do not wish to be contacted.

Treatment Alternatives:  We may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
 
Other permitted and required uses and disclosuresof PHI that may be made without your 
authorization:
 
The following are descriptions of each of the other purposes for which Brighton Bridge Hospice is permitted or required by the Hipaa/Hi-tech Privacy Regulations to use or disclose PHI without an individual’s authorization.  We may use or disclose your PHI in the following situations without your authorization.  These situations include:
 

1. Required by Law:  We may use or disclose your PHI to the extent that the use or disclosure is required by any Federal, State, or Local laws.  The use of disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified as required by law, of any such uses or disclosures.

 

2. Public Health:  We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  The disclosure will be made for the purpose of controlling disease, injury, or disability.  We may also disclose your PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

 

3. Communicable Diseases:  We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.  We may also disclose information to 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.  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.  Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.  Notify an employer about an individual who is a member of the employer’s workforce in certain limited situations, as authorized by law. 

 

4.  Health Oversight:  We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs, and civil rights law.  Hospice, however; may not disclose your PHI if you are the subject of an investigation and your health information is not directly related to your receipt of healthcare or public benefits.

 

5. Abuse or Neglect:  We may disclose your PHI to a public health authority that is authorized by law to receive reports of abuse or neglect.  In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable Federal and State laws.

 

6. Food and Drug Administration:  We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required. 

 

7. Legal Proceedings:  We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful processes.

 

8. Law Enforcement:  We may also disclose your PHI, provided applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.  As required by law for reporting of 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.
9. Coroners, Funeral Directors, and Organ Donation: We may also disclose your PHI to a Coroner of Medical Examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also contact the Coroner to discuss PHI when retrieving pronouncement of death.  We may also disclose PHI to a Funeral Director, as authorized by law, in order to permit the Funeral Director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  PHI may be used and disclosed for organ, eye, or tissue donation purposes of facilitating the donation and transportation.

 

10. Research Purposes: Hospice may, under certain circumstances, use and disclose your health information for research purposes.  Before Hospice discloses any of your PHI for research purposes, the project will be subject to an extensive approval process.  This process includes evaluating a proposed research project and its use of health information and trying to balance the research needs with your need for privacy.  Before Hospice uses or discloses health information for research, the project will have been approved through this research approval process.  Additionally, when it is necessary for research purposes and so long as the health information does not leave the Hospice, it may disclose your health information to researchers preparing to conduct a research project, for example, to help the researchers look for individuals with specific health needs.  Lastly, if certain criteria are met, Hospice may disclose your health information to researchers after your death when it is necessary for research purposes. 

 

11. Criminal Activity: Consistent with applicable Federal and State laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

 

12. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities (2) for the purpose of a determination by the Department of Veterans Affairs or your eligibility for benefits, or (3) to disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. 

 

13. Limited Data Set: Hospice may use or disclose a limited data set of your health information, that is, a subset of your health information for which all identifying information has been removed, for purposes or research, public health, or healthcare operations.  Prior to our release, any recipient of that limited data set must agree to appropriately safeguard your health information.

 

14. Serious Threat to Health or Safety: Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if Hospice, 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.

 

15. Specified Government Functions: In certain circumstances, the Federal regulations authorize Hospice 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.

 

16. Worker’s Compensation: Your PHI may be disclosed by us as to comply with worker’s compensation laws and other similar legally established programs.

 
Other Uses and Disclosures of PHI that may be made with your Authorization or Opportunity to Object:
 
We may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your healthcare will be disclosed.
 
 
Others involved in your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your healthcare.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose PHI to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death. If family or other significant other would like to retrieve information regarding your PHI, you or your representative will supply a list of the names that you wish to receive this information, however; persons on this list must supply a password that is given on admission that will be assigned specifically to you or your loved ones personal health file. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
 

Emergencies:  We may use or disclose your PHI in an emergency treatment situation.  Hospice submits this PHI to various agencies throughout the local city and statewide institutions that are equipped to utilize this data during emergency situations to assist in many ways.  
 
Uses and Disclosures of PHI based upon your Written Authorization:  Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization, at any time, in writing, except to the extent that our office has taken an action in reliance on the use or disclosure indicated in the authorization.
 
 
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
You have the following rights regarding your health information that Hospice maintain:

Right to request restrictions: You have the right to request restrictions on certain uses and disclosures on your health information.  You have the right to request a limit on Hospice’s disclosure of your health information to someone who is involved in your care or the payment of your care.  Hospice is not required to agree to your request, unless your request is for a restriction on a disclosure to a health plan for purposes of payment or healthcare operations (and is not for purposes of treatment) and the medical information you are requesting to be restricted from disclosure pertains solely to a healthcare item or service for which you have paid out of pocket in full.  You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  Your physician is not required to agree to a restriction that you may request.  If your physician does not agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restrictions you wish to request with your physician.
You have the right to request to receive confidential communications: You have the right to request that Hospice communicate with you in a certain way.  For example, you may ask that Hospice only conduct communications pertaining to your health information with you privately with no other family members present.  Hospice will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications. 
You have the right to amend your PHI:  You or your representative have the right to request that Hospice amend your records, if you believe that your health information is incorrect or incomplete.  That request may be made as long as the information is maintained by Hospice.  A request for an amendment of records must be made in writing to our agency’s Administrator, Maureen Smith at 337-639-9200.  Hospice may deny the request if it is not in writing or does not include a reason for the amendment.  The request also may be denied if your health information records were not created by the Hospice, if the records you are requesting are not part of the Hospice’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 Hospice, the records containing your health information are accurate and complete.
 
You have the right to inspect and copy your PHI: 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 Hospice agency administration office.  If you request a copy of your health information, Hospice may charge a reasonable fee for copying and assembling costs associated with your request.  You have the right to request that Hospice provide you, an entity or a designated individual with an electronic copy of your electronic health record containing your health information, if Hospice uses or maintains electronic health records continuing patient health information.  Hospice may require you to pay the labor costs incurred by Hospice in responding to your request. 
Under Federal law, however; you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this reviewed. Please contact the Administrator, Maureen Smith, at 337-639-9200 if you have questions about access to your medical record.
 
 
You have the right to receive an accounting: You or your representative have the right to request an accounting of disclosures of your health information made by Hospice for certain reasons, including reasons related to public purposes authorized by law and certain research.  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you.  An accounting request must be made in writing and submitted to the Hospice Administrator.  The request should specify the time period for the accounting starting on or after April 14, 2003.  Accounting requests may not be made for periods of time in excess of 7 years.
 
You have the 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 our Administrator, Maureen Smith, at (337)639-9200.
 
Brighton Bridge Hospice maintains a website that provides information
about it’s customer services.  Website address is: www.brightonbridge.com
                        
Breach Notification:  A Breach is an unauthorized acquisition, access, use or disclosure of PHI not permitted by the Privacy Rule.  A breach compromises the security or privacy of the PHI to such an extent that there is a significant risk of financial or other harm to the individual whose protected health information was wrongfully acquired, accessed, used or disclosed.  If a reportable breach has occurred, relevant information is gathered for the breach notification letter to be sent to affected individuals as soon as possible but no later that 60 calendar days from the date of the discovery of the breach.  The written breach notification letter will be sent by first class mail to the last known address of the affected individual(s).

Marketing and Protected Health Information:  Marketing communications of the Hospice may not involve the use or disclosure of an individual’s protected health information to encourage recipients to use services of the Hospice without your authorization in writing as required by Federal regulations.  For marketing communications that involve the use of disclosure of protected health information, your authorization is required unless the marketing communication:

1.  Takes place during a face-to-face encounter; or
2.  Involves products or services of nominal value.

The Hospice does not require your authorization for communications that:

1. Are about the participating providers and health plans in a network, the services offered by the providers, or the benefits covered by a health plan;
2. Are about your treatment; or
3. Involve case management or coordination of your care, or directions or recommendations for alternative therapies, providers, or settings of care.

Business Associates are not allowed to use protected health information for marketing purposes without your authorization.
 
DUTIES OF BRIGHTON BRIDGE HOSPICE WITH RESPECT TO YOUR PHI LEGAL DUTIES:
 
Brighton Bridge Hospice is required by law to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy practices with respect to PHI.  Through this Notice of Privacy Practices, we are providing you with this information.
 
 
CHANGES TO THIS NOTICE:
 
Hospice reserves the right to change this Notice and to make the new Notice provisions effective for all PHI that it maintains. Hospice reserves the right to make the revised Notice effective for health information we already have about you, as well as any health information we receive in the future.  We will post a copy of the current Notice in a clear and prominent location to which you have access.  The Notice also is available to you upon request.  The Notice will contain, at the end of this document, the effective date.  In addition, if Hospice revises the Notice, Hospice can offer you a copy of the current Notice in effect.
 

COMPLAINTS:
 
You or your personal representative has the right to express complaints to Hospice and to the Secretary of the U.S. Department of Health and Human Services if you or your representative believes that your privacy rights have been violated.  Any complaints to Hospice should be made in writing to Administration, Brighton Bridge Hospice, P.O. Box 279, Oberlin, La. 70655.  Hospice 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. 
 
 
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE:  Hospice has an Administrative staff to contact for all issues regarding patient privacy and your rights under the Federal privacy standards.  You may contact our office at (337)639-9200 and speak with Maureen Smith RN BC, Administrator; or visit our office at 213 B. Nth First Street; Oberlin, La. 70655.