NOTICE OF PRIVACY PRACTICES

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.

USE AND DISCLOSURE OF PHI

Arbor Hospice may use and disclose your health information, information that constitutes protected health information (PHI) as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Arbor Hospice has established policies to guard against unnecessary use and disclosure of your PHI. This Notice describes how we protect your PHI and what rights you have regarding your PHI.

Organized Health Care Arrangement. In our facility, care and services are provided to you by our Agency staff as well as by other health care providers. Although these providers are all independent, as you would expect they cooperate to provide an integrated system of care to you. This type of clinically integrated setting in which you receive health care from more than one health care provider is called an organized health care arrangement ("OHCA") under the HIPAA Privacy Standards. We may share your PHI with participants in the OHCA for treatment, payment and health care operations of the OHCA. This Notice of Privacy Practices is being provided on behalf of Arbor Hospice and any physician who serves as a Medical Director for the Agency that provides services for Arbor Hospice patients.

Arbor Hospice will comply with the more stringent Michigan state law in certain circumstances pertaining to disclosure of PHI related to HIV/AIDS, mental health, substance abuse and genetic testing.

Treatment, Payment and Health Care Operations
The most common reason we use your PHI is for treatment, payment or health care operations.

To Provide Treatment. Arbor Hospice may use your PHI to provide hospice and home health services and to coordinate your care with others involved in your care, such as your attending physician, members of the interdisciplinary team and other health care professionals who have agreed to assist us in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Unless you object, Arbor Hospice also may disclose your health care information to individuals outside of the Agency involved in your care, including family members, clergy who you have designated, pharmacists, suppliers of medical equipment, consultant physicians or other health care professionals.

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

To Conduct Health Care Operations. Arbor Hospice may use and disclose minimum necessary PHI about you for its own operations in order to facilitate the function of the Agency and as necessary to provide quality care to all of the Agency's patients. Health care operations includes such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.

For example Arbor Hospice may use your PHI to evaluate its staff performance, combine your PHI with other Agency patients in evaluating how to more effectively serve all Agency patients, and disclose your PHI to Arbor Hospice staff and contracted personnel for training purposes.

OTHER USES AND DISCLOSURES NOT REQUIRING AN AUTHORIZATION

Inclusion in Patient Directory. Arbor Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in the Agency's facility in a directory if you are in The Residence inpatient facility. Arbor Hospice 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.

For Appointment Reminders. Arbor Hospice may use and disclose your PHI to contact you as a reminder that you have an appointment for a home visit. Unless you object, we will use post cards for this purpose or leave messages for you on an answering machine or with someone who answers the telephone in your place of residence.

For Treatment Alternatives. Arbor Hospice may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Business Associates. Arbor Hospice will disclose your PHI to Business Associates that are contracted to perform business functions on our behalf. Whenever an arrangement between Arbor Hospice and a Business Associate involves the use or disclosure of your PHI, that Business Associate will be required to keep your PHI confidential. Business Associates are permitted to use your PHI only for purposes authorized by Arbor Hospice.

Incidental Disclosures. An authorization is not needed to cover disclosure of your PHI that is an unavoidable by-product of permitted use and disclosure.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR PHI MAY ALSO BE USED AND DISCLOSED

When Legally Required. Arbor Hospice will disclose your PHI when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health. Arbor Hospice may disclose your PHI for public activities and purposes in order 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, if such notification is authorized by law.

To Report Abuse, Neglect Or Domestic Violence. Arbor Hospice is allowed to notify government authorities if the Agency believes a patient is the victim of abuse, neglect or domestic violence. Arbor Hospice 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. Arbor Hospice may disclose your PHI to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Arbor Hospice, however, may not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.

In Connection With Judicial And Administrative Proceedings. Arbor Hospice may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your PHI.

For Law Enforcement Purposes. As permitted or required by State law, Arbor Hospice may disclose your PHI to a law enforcement official for certain law enforcement purposes as follows:

• 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.
• Under certain limited circumstances, when you are the victim of a crime.
• To a law enforcement official if the Agency has a suspicion that your death was the result of criminal conduct including criminal conduct at Arbor Hospice.
• In an emergency in order to report a crime.

To Coroners And Medical Examiners. Arbor Hospice may disclose your PHI to coroners and medical examiners for purposes of determining your cause of death, identifying a deceased person or for other duties, as authorized by law.

To Funeral Directors. Arbor Hospice may disclose your PHI to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Arbor Hospice may disclose your PHI prior to and in reasonable anticipation of your death.

For Organ, Eye Or Tissue Donation. Arbor Hospice may use or disclose your PHI 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.

In the Event of A Serious Threat To Health Or Safety. Arbor Hospice may, consistent with applicable law and ethical standards of conduct, disclose your PHI if the Agency, 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 Arbor Hospice to use or disclose your PHI 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. Arbor Hospice may release your PHI for worker's compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE PHI

Other than is stated above, Arbor Hospice will not disclose your PHI other than with your written authorization. If you or your representative authorizes Arbor Hospice to use or disclose your PHI, you may revoke that authorization in writing at any time.

For Research Purposes. The Agency will obtain a written authorization from you before it discloses your protected PHI for research purposes, unless the information is needed only for activities in preparation of research, the information is about deceased people or the Agency has received a copy of a proper waiver of authorization from an Institutional Review Board or Privacy Board in compliance with HIPAA.

For Fundraising Activities. The Agency may use and disclose demographic information about you (such as your name, address, and phone number), including the dates of health care provided to you by Arbor Hospice, in order to contact you or your personal representative in the future to raise money for our Agency. The money raised through these activities is used to expand and support the health care services and educational programs we provide to the community. If you do not wish to be contacted as part of our fundraising efforts, please notify the Privacy Official, (734) 662-5999 extension 158. The Agency will include in all its fundraising materials information about how you can let the Agency know that you do not want your information to be used for the Agency's fundraising. The Agency will obtain a written authorization from you before it uses any other protected PHI about you in fundraising.

For Marketing Purposes. Marketing means any communication by the Agency that encourages the person receiving the communication (recipient) to purchase our services. The Agency will obtain a written authorization from you before it uses or discloses your PHI in making a communication about a product or service that encourages the recipient to buy or use our service, or before making an arrangement with another entity under which the Agency receives direct or indirect payment from the entity in exchange for disclosing your PHI for marketing purposes by that entity. In other words, arrangements to use or sell your protected PHI for marketing are prohibited unless you give authorization for the Agency to do so, except when we market our own products or services, when the marketing communication is made as part of treatment, case management or care coordination, when we talk to you face to face or when we distribute promotional gifts of nominal value to you.

YOUR RIGHTS WITH RESPECT TO YOUR PHI

You have the following rights regarding your PHI that Arbor Hospice maintains:

• Right to request restrictions. You may request restrictions on certain uses and disclosures of your PHI. You have the right to request a limit on the Agency's disclosure of your PHI to someone who is involved in your care or the payment of your care. However, Arbor Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Official at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158.
• Right to receive confidential communications. You have the right to request that Arbor Hospice communicate with you in a certain way. For example, you may ask that the Agency only conduct communications pertaining to your PHI with you privately with no other family members present. If you wish to receive confidential communications, please contact the Privacy Official at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. Arbor Hospice 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 PHI. You have the right to inspect and copy your PHI, including billing records. A request to inspect and copy records containing your PHI may be made to the Privacy Official at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. If you request a copy of your PHI, Arbor Hospice may charge a reasonable fee for copying and assembling costs associated with your request.
• Right to amend health care information. You or your representative have the right to request that Arbor Hospice amend your records, if you believe that your PHI is incorrect or incomplete. That request may be made as long as the information is maintained by the Agency. A request for an amendment of records must be made in writing to the Privacy Official, who can be contacted at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. Arbor 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 PHI records were not created by Arbor Hospice, if the records you are requesting are not part of the Agency's records, if the PHI you wish to amend is not part of the PHI you or your representative are permitted to inspect and copy, or if, in the opinion of the Agency, the records containing your PHI are accurate and complete.
• Right to an accounting. You or your representative have the right to request an accounting of disclosures of your PHI made by Arbor Hospice for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to the Privacy Official, who can be contacted at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. 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 six (6) years. Arbor Hospice 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. To obtain a separate paper copy, please contact the Privacy Official at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. The patient or a patient's representative may also obtain a copy of the current version of the Arbor Hospice's Notice of Privacy Practices at its website, www.arborhospice.org.

ALL WRITTEN REQUESTS SHOULD BE MADE TO:
Privacy Official
Arbor Hospice
2366 Oak Valley Road
Ann Arbor, MI 48103

DUTIES OF ARBOR HOSPICE
Arbor Hospice is required by law to maintain the privacy of your PHI and to provide to you and your representative this Notice of its duties and privacy practices. Arbor Hospice is required to abide by the terms of this Notice as may be amended from time to time. Arbor Hospice reserves the right to change the terms of its Notice and our privacy policies and to make the new Notice provisions effective for all PHI that it maintains. Any changes will apply to the PHI we already have. If the Agency changes its Notice, Arbor Hospice will provide a copy of the revised Notice to you or your appointed representative while you are an active patient of the Agency. You may also read a copy of our Notice on the Arbor Hospice website at www.arborhospice.org. You or your personal representative has the right to express complaints to Arbor Hospice and to the Secretary of DHHS if you or your representative believes that your privacy rights have been violated. Any complaints to Arbor Hospice should be made in writing to the Privacy Official at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158. Arbor 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 Agency has designated the Director of Organizational Quality and Education as Arbor Hospice's Privacy Official. The Privacy Official is the contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at (888) 992-CARE (2273) ext. 158 or (734) 662-5999 ext. 158.

EFFECTIVE DATE
This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Privacy Official
Arbor Hospice
2366 Oak Valley Road
Ann Arbor, MI 48103
(734) 662-5999 ext. 158 or (888) 992-CARE (2273) ext. 158