Patient and Family’s Rights and Responsibilities

(a) A patient or resident shall not be denied appropriate care on the basis of race, religion, color, national origin, sex, age, disability, marital status, sexual preference, or source of payment.
(b) An individual who is or has been a patient or resident is entitled to inspect, or receive for a reasonable fee, a copy of his or her medical record upon request in accordance with the medical records access act, 2004 PA 47, MCL 333.26261 to 333.26271. Except as otherwise permitted or required under the health insurance portability and accountability act of 1996, Public Law 104-191, or regulations promulgated under the act, 45 CFR parts 160 and 164, a third party shall not be given a copy of the patient’s or resident’s medical record without prior authorization of the patient or resident.
(c) A patient or resident is entitled to confidential treatment of personal and medical records, and may refuse their release to a person outside the health facility or agency except as required because of a transfer to another health care facility, as required by law or third party payment contract, or as permitted or required under the health insurance portability and accountability act of 1996, Public Law 104-191, or regulations promulgated under that act, 45 CFR parts 160 and 164.
(d) A patient or resident is entitled to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect, and full recognition of his or her dignity and individuality. A patient or resident and their property are also entitled to being treated with respect by anyone providing services on behalf of the hospice.
(e) A patient or resident has the right to choose their attending physician who will oversee their care and work in collaboration with the hospice agency to provide care related to the terminal illness and related conditions.
(f) A patient or resident is entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the health facility or agency, information about his or her medical condition, proposed course of treatment, and prospects for recovery, in terms that the patient or resident can understand, unless medically contraindicated as documented by the attending physician in the medical record.
A patient or resident is entitled to be involved in the development of his or her plan of care and to be informed about the scope of services the hospice provides and any specific limitations on those services.
(g) A patient or resident is entitled to refuse treatment to the extent provided by law and to be informed of the consequences of that refusal. If a refusal of treatment prevents a health facility or agency or its staff from providing appropriate care according to ethical and professional standards, the relationship with the patient or resident may be terminated upon reasonable notice.
(h) A patient or resident is entitled to exercise his or her rights as a patient or resident and as a citizen, and to this end may voice grievances/complaints regarding treatment or care that is—or fails to be—provided, or recommend changes in policies and services on behalf of himself or herself or others to the health facility or agency staff, to governmental officials, or to another person of his or her choice within or outside the health facility or agency, free from restraint, interference, coercion, discrimination, or reprisal. A patient or resident is entitled to information about the health facility’s or agency’s policies and procedures for initiation, review, and resolution of patient or resident complaints.
(i) A patient or resident is entitled to information concerning an experimental procedure proposed as a part of his or her care and has the right to refuse to participate in the experimental procedure without jeopardizing his or her continuing care.
(j) A patient or resident is entitled to receive and examine an explanation of his or her bill regardless of the source of payment and to receive, upon request, information relating to financial assistance available through the health facility or agency.
(k) A patient or resident is entitled to know who is responsible for and who is providing his or her direct care, is entitled to receive information concerning his or her continuing health needs and alternatives for meeting those needs, and to be involved in his or her discharge planning, if appropriate.
A patient or resident is entitled to receive information about the services covered under the hospice benefit.
(l) A patient or resident is entitled to associate and have private communications and consultations with his or her physician, attorney, or any other person of his or her choice and to send and receive personal mail unopened on the same day it is received at the health facility or agency, unless medically contraindicated as documented by the attending physician in the medical record. A patient’s or resident’s civil and religious liberties, including the right to independent personal decisions and the right to knowledge of available choices, shall not be infringed and the health facility or agency shall encourage and assist in the fullest possible exercise of these rights. A patient or resident may meet with, and participate in, the activities of social, religious, and community groups at his or her discretion, unless medically contraindicated as documented by the attending physician in the medical record.
(m) A patient or resident is entitled to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. A patient or resident is entitled to be free from physical and chemical restraints, except those restraints authorized in writing by the attending physician for a specified and limited time or as are necessitated by an emergency to protect the patient or resident from injury to self or others, in which case the restraint may only be applied by a qualified professional who shall set forth in writing the circumstances requiring the use of restraints and who shall promptly report the action to the attending physician. In case of a chemical restraint, a physician shall be consulted within 24 hours after the commencement of the chemical restraint.
(n) A patient or resident is entitled to be free from performing services for the health facility or agency that are not included for therapeutic purposes in the plan of care.
(o) A patient or resident is entitled to information about the health facility or agency rules and regulations affecting patient or resident care and conduct.
(p) A patient or resident is entitled to be informed and receive written information concerning the hospice’s policy on advance directives, including state law and regulation.
(q) A patient or resident is entitled to adequate and appropriate pain and symptom management as a basic and essential element of his or her medical treatment, for conditions related to the terminal illness.
Responsibilities of patient or resident

A patient or resident is responsible for following the health facility rules and regulations affecting patient or resident care and conduct.
A patient or resident is responsible for providing a complete and accurate medical history.
A patient or resident is responsible for making it known whether he or she clearly comprehends a contemplated course of action and the things he or she is expected to do.
A patient or resident is responsible for following the recommendations and advice prescribed in a course of treatment by the physician.
A patient or resident is responsible for providing information about unexpected complications that arise in an expected course of treatment.
A patient or resident is responsible for being considerate of the rights of other patients or residents and health facility personnel and property.
A patient or resident is responsible for providing the health facility with accurate and timely information concerning his or her sources of payment and ability to meet financial obligations.

MECHANISM FOR THE INITIATION, INVESTIGATION AND RESOLUTION OF COMPLAINTS IN ACCORDANCE WITH ARBOR HOSPICE POLICY:

Patients/families may complain to either Arbor Hospice, the Michigan Department of Licensing and Regulatory Affairs (LARA) or Community Health Accreditation Partner (CHAP) about any condition, event, or procedure in the hospice, with or without citing a specific violation of the state code.
A patient/family may submit written or oral complaints to Arbor Hospice.
Arbor Hospice will assist a complainant in reducing an oral complaint to writing, when such oral complaint is not resolved to the satisfaction of the complainant, upon request.
The name, title, location and telephone number of the individual at Arbor Hospice who is responsible for receiving complaints and conducting complaint investigations is provided at the time of enrollment and is in this memorandum.
For purposes of this standard, a complaint will be defined as any dissatisfaction expressed by a patient or family that is presented directly to the Director of Organizational Integrity, either orally or in writing. Other issues that may surface from time to time but that are mutually resolved in lower levels of the organization will not be regarded as complaints.
All complaints will be investigated within five (5) working days following receipt of the complaint.
Within fifteen (15) working days following receipt of a complaint, Arbor Hospice will deliver to the complainant a written report of the results of the investigation. If the complainant is not satisfied with the investigation or resolution of the complaint, they may file an appeal to the Hospice Administrator.
Arbor Hospice will maintain written complaints filed under the complaint procedure, and all complaint investigation reports delivered to each complainant, for three (3) years. Such records will be made available to LARA upon request.

If you have any questions about this notice, please contact the Director of Organizational Integrity.
Contact Information for filing complaints:

Director of Organizational Integrity
2366 Oak Valley Dr., Ann Arbor, MI 48103
Phone: (888) 247-5701

Michigan Dept. of Licensing and Regulatory Affairs
Phone: 800-882-6006

Community Health Accreditation Partner
Phone: 800-656-9656

Contact Information for Hospice Administrator to file an appeal:

Hospice Administrator
Phone: (888) 247-5701

Privacy Notice

Terms used, but not defined, in this notice have the meanings set forth in the Federal HIPAA Law.

WHO WILL FOLLOW THIS NOTICE

This notice describes Hospice’s practices and that of:

Any health care professional authorized to enter information into your Hospice chart.
All departments and units and facilities and site locations of Hospice.
Any member of an organized healthcare arrangement in which Hospice participates (i.e., this notice may cover more than one covered entities’ activities – all members of the organized healthcare arrangement have agreed/will agree to abide by the terms of this notice).
Any member of a volunteer group we allow to help you while you are under Hospice’s care.
All employees, staff and other Hospice personnel.
All these entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

Hospice understands that medical information about you and your health is personal, and Hospice is committed to protecting medical information about you. Hospice creates a record of the care and services you receive at Hospice. Hospice needs this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Hospice, whether made by Hospice personnel or another health care provider. Your other health care providers may have different policies or notices regarding their use and disclosure of your medical information they create or maintain.
This notice will tell you about the ways in which Hospice may use and disclose medical information about you. This notice also describe your rights and certain obligations Hospice has regarding the use and disclosure of medical information.
Hospice is required by law to:

Make sure that medical information that identifies you is kept private (with certain exceptions);
Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that Hospice uses and discloses medical information. For each category of uses or disclosures Hospice will explain what we mean and try to give some examples. Not every specific use or disclosure or type of use/disclosure in a category will be listed. However, all of the ways Hospice is permitted to use and disclose information will fall within one of the categories. Any other uses and disclosures not described in this notice will not be made without your authorization.
If, in any case, medical information is used or disclosed in violation of the law, we are required to notify you if the use/disclosure is a “Breach of Unsecured Protected Health Information” (as such terms are defined by the Federal
HIPAA Law).
Our records may contain information regarding your mental health and/or substance abuse. Records involving mental health, substance abuse, pregnancy or sexually transmitted diseases, or other types of sensitive/protected information, may be protected by additional restrictions under state and federal law, which we will comply with.
Disclosure at Your Request. Hospice may disclose information when requested by you. This disclosure at your request may require a written authorization by you. Any authorizations that you give can be revoked at any time.
Psychotherapy Notes and Marketing. Your authorization is required for most uses and disclosures of any of your medical information involving psychotherapy notes. Your authorization is required for most uses and disclosures of your medical information for “Marketing” purposes, including subsidized treatment communications, or for disclosures that constitute the “Sale” of medical information. Please be aware, however, that HIPAA’s definitions of “Marketing” and “Sales,” and the restrictions related thereto, are technical, and do not apply to all situations that you may consider to be marketing or sales. Hospice will use and/or disclose medical information for marketing or sales in accordance with HIPAA and state law, which in some, but not all, situations requires your authorization to do so.
For Treatment. Hospice may use medical information about you to provide you with medical treatment, healthcare, or other related services (including for care coordination purposes). Hospice may disclose medical information about you to doctors, nurses, aids, technicians, health care students, or other Hospice personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes so that we can arrange for appropriate meals. Different departments of Hospice also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. Hospice also may disclose medical information about you to people outside Hospice who may be involved in your medical care after you leave Hospice, such as family members, skilled nursing facilities, home health agencies, and physicians or other practitioners. For example, Hospice may give your physician access to your health information to assist your physician in treating you.
For Payment. Hospice may use and disclose medical information about you so that the treatment and services you receive at Hospice may be billed to and payment may be collected from you, an insurance company or a third party. Hospice may also disclose your medical information to another health care provider or payor of health care for the payment activities of that entity. For example, Hospice may need to give your health plan information about surgery you received at Hospice so your health plan will pay Hospice or reimburse you for the surgery. Hospice may also tell your health plan about a treatment you are going to receive to obtain prior approval, referrals, or to determine whether your plan will cover the treatment. Hospice may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside Hospice who are involved in your care, to assist them in obtaining payment for services they provide to you. Hospice may also need to use and disclose your medical information in various appeals processes to defend the necessity of services offered in the past, and to pursue collections actions for services which we have rendered to you.
If you do not want to disclose medical information about you to your health plan, you have the right to pay for all procedures and care out of pocket, and to inform us that you wish to restrict the information disclosed to your health plan. Under federal law, we must comply with certain restrictions on disclosures of your protected health information if you have paid out of pocket in full. For more information, see your rights listed below.
For Health Care Operations. Hospice may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run Hospice and make sure that all of our patients receive competent, quality health care, and to maintain and improve the quality of health care that Hospice provides. Hospice may also provide your medical information to various governmental or accreditation entities to maintain Hospice license(s) and accreditation. For example, Hospice may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. Hospice may also combine medical information about many Hospice patients to decide what additional services Hospice should offer, what services are not needed, and whether certain new treatments are effective. Hospice may also disclose information to doctors, nurses, technicians, medical students, and other Hospice personnel for review and learning purposes. Hospice may also combine the medical information Hospice has with medical information from other health care providers to compare how Hospice is doing and see where Hospice can make improvements in the care and services Hospice offers. Hospice may remove information that identifies you from this set of medical information so others may use it to study health care delivery without identifying who the specific patients are.
Incidental Uses and Disclosures. Hospice may occasionally inadvertently use or disclose your medical information when such use or disclosure is incident to another use or disclosure that is permitted or required by law. For example: while Hospice has safeguards in place to protect against others overhearing conversations that take place between doctors, nurses or other personnel, there may be times that such conversations are in fact overheard. Please be assured, however, that as much as possible, Hospice has appropriate safeguards in place in an effort to avoid such situations.
Limited Data Sets. Hospice may use or disclose certain parts of your medical information, called a “limited data set,” for purposes of research, public health reasons or for our health care operations. Hospice would disclose a limited data set, only to third parties that have provided us with satisfactory assurances that they will use or disclose your medical information only for limited purposes.
Disclosures to the Secretary of Health and Human Services. Hospice might be required by law to disclose your medical information to the Secretary of the Department of Health and Human Services, or his/her designee, in the case of a compliance review to determine whether Hospice is complying with privacy laws.
De-identified Information. Hospice may use your medical information, or disclose it to a third party whom Hospice has hired, to create information that does not identify you in any way. Once Hospice has de-identified your information, it can be used or disclosed in any way according to law.
Disclosures by Members of Hospice’s Workforce. Members of Hospice’s workforce, including employees, volunteers, trainees or independent contractors, may disclose your medical information to a health oversight agency, public health authority, health care accreditation organization or attorney hired by the workforce member, to report the workforce member’s belief that Hospice has engaged in unlawful conduct or that our care or services could endanger a patient, workers or the public. In addition, if a workforce member is a crime victim, the member may disclose your medical information to a law enforcement official.
Sharing within Organized Health Care Arrangements. Covered entities participating in any organized health care arrangement in which we participate may/will share medical information with each other, as necessary to carry out treatment, payment, or health care operations relating to the organized health care arrangement.
Organized Reminders. Hospice may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the Hospice. If you do not wish Hospice to contact you regarding appointment reminders, you must notify Hospice in writing and state that you wish to be excluded from this activity.
Treatment Alternatives. Hospice may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. If you do not wish Hospice to contact you regarding treatment alternatives, you must notify Hospice in writing and state that you wish to be excluded from this activity.
Health-Related Products and Services
Hospice may use and disclose medical information to tell you about our health-related products or services that may be of interest to you. If you do not wish Hospice to contact you regarding health related-products and services, you must notify Hospice in writing and state that you wish to be excluded from this activity.
Fundraising Activities. Hospice may use medical information about you, or disclose such information to a foundation related to Hospice or a fundraising-related service provider, to contact you in an effort to raise money for Hospice and its operations. Hospice only would release contact information, such as your name, address and phone number and the dates you received treatment or services at Hospice. If you do not want Hospice to contact you for fundraising efforts, you have the right to opt out by notifying our Privacy Officer (contact information is set forth at the very end of this notice) in writing.
Facility Director. Hospice may include certain limited information about you in the Hospice directory while you are a patient at Hospice. This information may include your name, location in Hospice, your general condition (e.g., good, fair, etc.), and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This information is released so your family, friends and clergy can visit you at Hospice and generally know how you are doing.
To Individuals Involved in Your Care or Payment for Your Care. Hospice may release medical information about you to a friend or family member who is involved in your medical care. Hospice may also give information to someone who helps pay for your care. Unless there is a specific written request from you to the contrary, Hospice may also tell your family or friends your condition and that you are at Hospice.
In addition, Hospice may disclose certain medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, Hospice is required to attempt to contact someone Hospice believes can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).
For Research. Under certain circumstances, Hospice may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before Hospice uses or discloses medical information for research, the project will have been approved through this research approval process, but Hospice may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, as long as the medical information they review does not leave Hospice.
As Required by Law. Hospice will disclose medical information about you when required to do so by federal, state or local law.
To Avert a Serious Threat To Health or Safety. Hospice may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or reduce the threat, or to law enforcement in particular circumstances.
Third Parties. Hospice may disclose your medical information to third parties with whom Hospice has contact to perform services on Hospice’s behalf. If Hospice discloses your information to these entities, Hospice will have a written agreement with them to safeguard your information.

SPECIAL SITUATIONS

Organ and Tissue Donation. Hospice may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, Hospice may release medical information about you as required by military command authorities. Hospice may also release medical information about foreign military personnel to the appropriate foreign military authority.
Worker’s Compensation. Hospice may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Activities. Hospice may disclose medical information about you for public health activities. These activities generally include the following:

To prevent or control disease, injury or disability;
To report births and deaths;
To report regarding the abuse or neglect of children, elders, and dependent adults;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Hospice will only make this disclosure if you agree or when required or authorized by law;
To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

Health Oversight Activities. Hospice may disclose medical information 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.

LAWSUITS AND DISPUTES

If you are involved in a lawsuit or a dispute, Hospice may disclose medical information about you in response to a court or administrative order. Hospice may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

LAW ENFORCEMENT

Hospice may release certain medical information if asked to do so by a law enforcement official:

As required by law;
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, Hospice is unable to obtain the person’s agreement;
About a death Hospice believe may be the result of criminal conduct;
About criminal conduct at Hospice; and
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

Coroners, Medical Examiners and Funeral Directors. Hospice may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Hospice may also release medical information about patients of Hospice to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. Hospice may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for President and Others. Hospice may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, Hospice may disclose medical information about you to the correctional institution or law enforcement official. This disclosure would be necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or 3) for the safety and security of the correctional institution.
Multidisciplinary Personnel Teams. Hospice may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.
Special Categories of Information. In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use of disclosure of certain categories of information — e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as state Medicaid programs, may also limit the disclosure of beneficiary information for purposes unrelated to the program.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information Hospice maintains about you.
Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer (contact information is set forth at the very end of this notice). If Hospice uses or maintains your medical information in an electronic health record, you have the right to obtain an electronic copy of such information. Furthermore, you have the right to direct Hospice to transmit such electronic copy directly to another entity or person that you designate. If you request a copy of the information, Hospice may charge a fee for the costs of copying, mailing or other supplies associated with your request.
Hospice may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Hospice will review your request and the denial. The person conducting the review will not be the person who denied your request. Hospice will comply with the outcome of the review.
We may charge a reasonable cost based fee for labor in copying medical information and postage when you request information be transmitted by mail or courier.
Right to Electronic Access. You have the right to access electronic copies of your medical information when requested. When information is not readily producible in the form and format requested, we will provide you the information in an alternative readable electronic format as we may mutually agree upon.
Right to Amend. If you feel that medical information Hospice has about you is incorrect or incomplete, you may ask Hospice to amend the information. You have the right to request an amendment for as long as the information is kept by or for Hospice.
To request an amendment, your request must be made in writing and submitted to our Privacy Officer (contact information is set forth at the very end of this notice). In addition, you must provide a reason that supports your request.
Hospice may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Hospice may deny your request if you ask Hospice to amend information that:

Was not created by Hospice, unless the person or entity that created the information is no longer available to make the amendment;
Not part of the medical information kept by or for Hospice;
Not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

Even if Hospice denies your request for amendment, you have the right to submit a written statement of disagreement with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the statement of disagreement to be made part of your medical record, Hospice will attach it to your records and include it whenever Hospice makes a disclosure of the item or statement you believe to be incomplete or incorrect.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures Hospice made of medical information about you other than our own uses for treatment, payment and health care operations (as those functions are described above) Hospice, and with other exceptions pursuant to the law. If, however, Hospice is using an electronic health record, Hospice will also account for treatment, payment and health care operations made using the electronic health record.
To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer (contact information is set forth at the very end of this notice). Your request must state a time period which may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, Hospice may charge you for the costs of providing the list. Hospice will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
In addition, Hospice will notify you as required by law if your health information is unlawfully accessed or disclosed.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information Hospice uses or discloses about you for treatment, payment or heath care operations. You also have the right to request a limit on the medical information Hospice discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that Hospice not use or disclose information about a surgery you had.
Hospice is generally not required to agree to your restriction request.
In one narrow instance, however, we are required to agree to the request, if all of the following apply: (i) you have requested that we restrict disclosure for payment or healthcare operations purposes; (ii) the disclosure would be made to a health plan/insurer (e.g., we are not precluded from making other allowable disclosures, only disclosures to the health plan/insurer); (iii) the disclosure is not otherwise required by law; and (iv) the PHI restricted pertains solely to a healthcare item or service for which you, or someone on your behalf, have paid us in full (excluding payments made by the health plan on your behalf) (e.g., you may not restrict the entirety of your medical record from being disclosed to a health plan/insurer – you may only restrict the portions of your record for those items or services which have been paid in full). You are hereby advised that, even if you utilize this required restriction request and meet the criteria set forth above, the required restriction is narrow. In particular, even if you have requested and received a required restriction, we may still disclose your information to others for other allowable purposes, such as sending information to a pharmacy to have a prescription filled. In the event that we make such allowable disclosures, the party to which we have permissibly disclosed the information to is not bound by the required restriction request that you made to us, and we are not obligated to relay your request to such party. The only way for you to guarantee that such 3rd parties do not then disclose said information to your insurer/health plan is for you to make a required restriction request with the 3rd party that meets all of the required restriction elements set forth above. We hereby advise you to do so if you desire.
If Hospice does agree to comply with other non-required requests, Hospice will comply with your request unless (a) the information is needed to provide you emergency treatment, or (b) other legal exceptions apply.
To request restrictions, you must make your request in writing to our Privacy Officer (contact information is set forth at the very end of this notice). Hospice will not ask you the reason for your request. Hospice will attempt to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Receive Confidential Communications. You have the right to request that Hospice communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Hospice only contact you at work or by mail.
To request confidential communications, you must make your request in writing to our Privacy Officer (contact information is set forth at the very end of this notice). Hospice will not ask you the reason for your request. Hospice will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website: www.hom.org.
To obtain a paper copy of this notice, ask our admissions professionals, or our Privacy Officer (contact information is set forth at the very end of this notice).
Right to be Notified in the Event of a “Breach of Unsecured PHI”. If, in any case, medical information is used or disclosed in violation of the law, we are required to notify you if the use/disclosure is a “Breach of Unsecured Protected Health Information” (as such terms are defined by the Federal HIPAA Law).

CHANGES TO THIS NOTICE

Hospice reserves the right to change this notice. Hospice reserves the right to make the revised or changed notice effective for medical information we already have about you as well as any information Hospice receives in the future. Hospice will post a copy of the current notice in Hospice’s facilities. The notice will contain the effective date on the first page, in the top right-hand corner. In addition, each time you register at or are admitted to Hospice for treatment or health care services as an inpatient or outpatient, Hospice will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Hospice or with the Secretary of the U.S. Department of Health and Human Services.
To file a complaint with Hospice, contact our Privacy Officer in writing (contact information is set forth at the very end of this notice). All complaints must be submitted in writing.
You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION/PERMISSIONS/AUTHORIZATIONS

Other uses and disclosures of medical information not covered by this notice or the laws that apply to Hospice will be made only with your written permission/authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if Hospice has already acted in reliance on your permission. You understand that Hospice is unable to take back any disclosures Hospice has already made with your permission, and that Hospice is required to retain Hospice’s records of the care that Hospice provided to you.
privacy officer

CONTACT INFORMATION

If you have any questions about this notice, please contact our Privacy Officer utilizing the contact information set forth below.
Privacy Officer
2366 Oak Valley Dr., Ann Arbor, MI 48103
Phone: (888) 247-5701
Certain provisions of this notice and our related policies and procedures require that notice or other requests be in writing. Please follow our instructions for any such issue.