Lopez Island Hospice and Home Support HIPAA DOCUMENTS

• Privacy Statement
• Other Uses of information

Lopez island Hospice and Home Support (LIHHS) is required by law to maintain the privacy of protected health information and to provide you adequate notice of your rights and our legal duties and privacy practices with respect to the uses and disclosures of protected health information. We will use or disclose protected health information in a manner that is consistent with this notice.

LIHHS maintains a record (paper/electronic file) of the information we receive and collect about you and of the care we provide to you. This record includes information about your current living situation, your ability to perform activities of daily living, the assistance you are requesting from LIHHS, your medical diagnosis, assessments and progress notes. It also lists designated family members or caregivers, the name of your healthcare provider(s) and your choices about Advance Directives.

For Treatment: Information obtained by LIHHS will be recorded in your record and used to develop, implement and maintain your plan of care. For example the Volunteers assigned to assist you meet regularly with the LIHHS Case Manager to review the appropriateness of your plan of care.

For payment: all service provided by LIHHS is free of charge. LIHHS does not bill you or anyone else for any service that we provide. Therefore we do not share any information for purposes of receiving payment.

For health care operations: We may use your record to assess quality and improve services. We may contact you to remind you of appointments or other health related benefits and services.

The records we create and store are the property of LIHHS. The protected health information in it, however, generally belongs to you. You have a right to:

• Receive, read, and ask questions about this Notice;
• Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request. But we will comply with any request granted;
• Request and receive from us a paper copy of the most current Notice of Privacy Practices for Protected health Information "Notice";
• Request that you be allowed to see and get a copy of your protected health information. You must make this request in writing.
• Have us review a denial of access to your health information-except in certain circumstances
• Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in you record and included with any release of your records.
• When you request, we will give you a list of disclosures of your health information. The list will not include disclosures made for purposes of treatment, payment or healthcare operation, disclosures you authorized, disclosures to you, incidental disclosures, disclosures to family or other persons involved in your care, disclosures to correctional institutions, and law enforcement in some circumstances, disclosures of limited data set information or disclosures for national security. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request the information more than once in 12 months.
• Ask that your health information be given to you by another means or at another location. Please sign, date, and give us your request in writing.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
• We will arrange for you to receive protected health information by reasonable alternative means or at alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.

The following uses and disclosures do not require your consent, and include, but are not limited to, a release of information contained in your case record including information concerning communicable diseases such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or other related information to:

1. Any hospital, nursing home or other health care facility to which you may be admitted;
2. Any assisted living or personal care facility of which you are a resident;
3. Any physician providing you care;
4. Contact you to provide appointment reminders or information about other health activities we provide;
5. Other health care providers to initiate treatment.

• Keep your protected health information private;
• Give you this notice;
• Follow the terms of this Notice

We have the right to change our practices regarding this Notice. You may receive the most recent copy of this Notice by calling and asking for it to be sent to you.

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact the

LIHHS Privacy Officer
PO Box 747
Lopez Island WA 98261
360-468-4446

If you believe your privacy rights have been violated, you may discuss your concerns with the privacy officer. You may also deliver a written complaint. You may also file a complaint with the U. S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

OTHER DISCLOSURES AND USES OF PROTECTED HEALTH INFORMATION
Unless you object, we may release information about you to a friend or family member who is involved in your care. In addition, we may disclose information about you to assist in disaster relief efforts.

You have the right to object to this use or disclosure of you information. If you object, we will not use or disclose it.

WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION AS FOLLOWS:

For Public Health and Safety Purposes as Allowed or required by Law:

• To prevent or reduce a serious, immediate threat to the health or safety of a person or the public
• To public health or legal authorities to protect public health and safety
• To report suspected Abuse or Neglect to public authorities
• In emergency situations, if we attempt to obtain consent as soon as practicable after treatment
• Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances
• Where we are required by law to provide treatment and we are unable to obtain consent
• Where the use or disclosure of medical information about you is required by federal, state or local law
• To provide information to state or federal public health authorities, as required by law to: prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence (if you agree or when required or authorized by law);

OTHER DISCLOSURE AND USES OF PROTECTED HEALTH INFORMATION Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

WEB SITE
We have a Web site that provides information about us. For your benefit, the Notice is on the Web site at this address: www.lihhs.org.

Effective Date: 12-01-03

Lopez island hospice and Home Support will inform the client in writing if Personal Health Information is to be used in any other manner than those stated in the Privacy Statement.

LIHHS will state in writing that the client has the right to refuse LIHHS the use of the information.

LIHHS will inform the client in writing what information will be disclosed and to whom.

LIHHS will inform the client in writing that once disclosed, the information is no longer protected.

LIHHS will inform the client in writing that permission may be revoked.