To Provide Treatment:
The Hospice may use your health information to coordinate care within the hospice team 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 the Hospice in coordinating care/services. For example, information about your symptoms will need to be reported to the physicians in order to obtain appropriate prescriptions for symptom management. The Hospice may also disclose your health care information to individuals outside the hospice team in effort to coordinate care. This may include family members, clergy whom you have designated, pharmacists, suppliers of durable medical equipment and/or other health care professionals that the Hospice uses in order to coordinate your care. The hospice will send out weekly appointment reminders to contract nursing homes to notify them of scheduled staff visits to see their hospice patients. Information may be disclosed to community Social Service Agencies in an effort to provide linkage for care resources desired by the patient or representative.

To Obtain Payment:
The Hospice may include your health information in invoices to collect payment from third parties for the care you may receive from the Hospice. For example, the Hospice may be required to provide health care information regarding your health status so that the insurer will reimburse Hospice for services provided.

To Conduct Health Care Operations:
The Hospice may use and disclose health care information for its own operations in order to facilitate the function of the Hospice and as necessary to provide quality care to all of the Hospice's patients. Health care operations includes the following activities:

Quality assessment and improvement activities

Activities designed to improve health care delivery or reduce health care costs

Case management and care coordination

Professional review and performance evaluation

Training programs including those in which trainees or practitioners in health care learn under supervision

Volunteer training

Memorial services for Hospice families

Certification, accreditation, licensing or credentialing activities

Review and auditing for purpose of compliance programs and legal services.

Business planning and development including cost management and planning related analyses.

Business management and general administrative activities of the Hospice

For example, your health information may be used to evaluate the performance of Hospice staff, combine your health information with other Hospice patients in determining how to more effectively meet the needs of all patients served by Hospice, disclose your health information to train Hospice staff.
Federal privacy rules allow the Hospice to use or disclose your health information without your consent or authorization for a number of reasons.

When Legally Required:
The Hospice will disclose your health information when it is required to do so by Federal, State or local law.

When There Are Risks To Public Health:
The Hospice may disclose your health information for public activities and purposes in order to:

Prevent or control disease, injury or disability, report disease, injury, vital events such as a birth or death and the conduct of public health surveillance, investigations and interventions.

To report adverse events, product defects, to enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.

To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect or Domestic Violence:
The Hospice is mandated to notify government authorities if the Hospice believes a patient is the victim of abuse, neglect or domestic violence.

To Conduct Health Oversight Activities:
The Hospice may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Hospice 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:
The Hospice may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative hearing as expressly authorized by such order or in response to a subpoena, discovery request or other legal process. The hospice must make all efforts to either notify you about the request or to obtain an order protecting your health information before disclosing the information.

For Law Enforcement Purposes:
The Hospice may disclose your health information to a law enforcement official for purposes as follows:

As required by law for reporting of certain types of 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.

For the purpose of preventing or lessening a serious and imminent threat to your health or safety or to the health and safety of the public, in accordance with applicable law and ethical standards of conduct.

Under certain limited circumstances, when you are the victim of a crime or the Hospice believes that disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the safety of the public.

To a law enforcement official if the Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct on the part of Hospice.

In an emergency situation where a crime must be reported.

To Coroners and Medical Examiners:
The Hospice may disclose your health information for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors:
The Hospice may disclose your health information to funeral directors consistent with applicable law and, if necessary, to carry out their duties with respect to your funeral arrangements.

For Organ, Eye or Tissue Donation:
The Hospice 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 for the purpose of facilitating the donation and transplantation, according to your specific wishes.

For Research Purposes:
At present Hospice Care of the Northwest Hospice does not participate in any research activities that would require disclosure of PHI. If this would change Hospice Care of the Northwest Hospice would amend or develop standards to meet compliance and notify our patients and families of such change.

For Specified Government Functions:
In certain circumstances, Federal Regulations authorize that Hospice to use and disclose the protected 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:
The Hospice may disclose your health Information for worker's compensation or other similar programs established by law.

AUTHORIZATIONS TO USE AND DISCLOSE HEALTH INFORMATION
Other than is stated above, Hospice Care of the Northwest will not disclose your health information other than with your written authorization. If you or your representative authorizes Hospice Care of the Northwest 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
You have the following rights regarding your health information that the Hospice maintains:

Right to request restrictions. You have the right to request a limit on the Hospice's disclosure of your health information to someone who is involved in your care or the payment of services for your care. However, the Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the Executive Director for Hospice Care of the Northwest Hospice.

Right to receive confidential communications. You have the right to request that the Hospice communicate with you in a certain way. For example, you may ask that the Hospice only conduct communications pertaining to your health information with you privately without other family members present. If you wish to receive confidential communications, please contact the Executive Director for Hospice Care of the Northwest Hospice. Hospice Care of the Northwest does not require 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 Executive Director for Hospice Care of the Northwest Hospice. If you request a copy of your health information, the Hospice 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 believe that your health information records are incorrect or incomplete, you may request that the Hospice amend the records. That request may be made as long as the information is maintained by the Hospice. A request for an amendment of records must be made in writing to the Executive Director for Hospice Care of the Northwest Hospice. The 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 Hospice Care of the Northwest Hospice, are not part of Hospice Care of the Northwest Hospice's records or if, in the opinion of Hospice Care of the Northwest Hospice, 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 the Hospice for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Executive Director of Hospice Care of the Northwest Hospice. The request should specify the time period for the accounting, which must start on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. The Hospice 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.

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 the Executive Director for Hospice Care of the Northwest Hospice.

DUTIES OF THE HOSPICE
The Hospice 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. The Hospice is required to abide by terms of this notice as may be amended from time to time. The Hospice reserves the right to change the terms of its notice and to make the new notices' provisions effective for all health information that it maintains. If the Hospice changes its notice, the Hospice will provide a copy of the revised notice to you or your representative. You or your personal representative have the right to express complaints to the Hospice and the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to the Hospice should be made in writing to the Executive Director for Hospice Care of the Northwest Hospice. The 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.

CONTACT PERSON
The Hospice's contact person for all issues regarding patient privacy and
your rights under the Federal privacy is the Executive Director.

Hospice Care of the Northwest Hospice
800 Roosevelt Rd.
Building C - Suite 206
Glen Ellyn, IL 60137
Phone: 800-419-0542

EFFECTIVE DATE: This Notice is effective April 14, 2003