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 HEALTH INFORMATION
Covenant Hospice, Inc., hereinafter referred to as “Covenant,” may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed only after the Hospice has obtained your written consent. In many cases written consent is obtained upon admission to our services. Covenant has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT:

To Provide Treatment.
Covenant may use your health information to coordinate care with physician(s), members of the Covenant Interdisciplinary Team (nurses, social workers, chaplains, home health aides and volunteers), and other health care professionals who have agreed to assist Covenant in coordinating the care and services we provide. For example, a physician involved in your care may need to know what current medications you are on and information about your symptoms in order to prescribe appropriate medications. Covenant may also disclose your health care information to individuals outside of Covenant involved in your care. These individuals may include; pharmacists, suppliers of medical equipment or other health care professionals that Covenant uses in order to coordinate your care. Covenant may also disclose your health care information to those most closely involved in your care such as family members or clergy whom you have designated.
To Obtain Payment.
Covenant may include your health information in invoices to collect payment from third parties, such as Medicare/Medicaid or other health insurance providers, for the care you may receive from Covenant. For example, Covenant may be required by your health insurance provider to provide information regarding your health care status so that the health insurance provider will reimburse you or Covenant. Covenant may also need to obtain prior approval from your health insurance provider and may need to explain to the health insurance provider your need for hospice care and the services Covenant may be providing to you.
To Conduct Health Care Operations.
Covenant may use and disclose health care information for its own operations in order to facilitate the function of Covenant and as necessary to provide quality care to you and all of Covenant’s patients. Health Care Operations including, but not limited to activities such as:
• Performance Improvement Activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Training of non-health care 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 Covenant
• Fundraising for the benefit of the Hospice with certain marketing activities.

For example Covenant may use your health information in combination with other Covenant patients’ information during a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey, in the evaluation process to see if Covenant is providing the quality of care we have been awarded for, to evaluate the care and services Covenant provides in order to evaluate how to more effectively serve all Covenant patients, to contact you to schedule visits according to your needs, or to contact you or your family as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).
Hospice Residence And Conducting Health Care Operations
Covenant may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in the Residence on a list while you are in the Residence. Covenant 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 on the list.
For Fundraising And Outreach Activities
Covenant may use minimal information about you including your name, in order to acknowledge donations from you or your family, or donations made on your behalf. The list of contributors and memorials of may be released to our Foundation. Covenant only sends generic mailings requesting donations. If you or your family do not wish to be contacted, please notify our Development Department, Lisa Clopton, at (850) 438-9714, and we will remove this information from our listings.
When Legally Required.
Covenant will disclose your health information when it is required to do so by any Federal, State or local laws.
When There Are Risks to Public Health.
Covenant may disclose your health information of 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.
• To 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.
• 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.
Covenant is allowed to notify government authorities if we believe you are a victim of abuse, neglect or domestic violence. Covenant will make this disclosure only when specifically required or authorized by law or when you agree to the disclosure.
To Conduct Health Oversight Activities
Covenant may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Covenant, 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.
Covenant may disclose your health information 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 Covenant makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes.
Covenant may disclose your health information to a law enforcement official for 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 Covenant has a suspicion that your death was the result of a criminal conduct including criminal conduct at Covenant
• In an emergency in order to report a crime.
To Coroners And Medical Examiners
Covenant may disclose your health information to coroners and medical examiners for the purpose of determining your cause of death or for other duties, as authorized by law.
To Funeral Directors.
Covenant 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. If necessary to carry out their duties, Covenant may disclose your health information prior to and in reasonable anticipation, of your death.
For Organ, Eye Or Tissue Donation.
Covenant may 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.
For Research Purposes.
Covenant may, under very select circumstances, use your health information for research. Before Covenant discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Covenant will ask your permission if any researcher will be granted access to your individually identifiable health information.
In The Event Of A Serious Threat To Health Or Safety.
Covenant may, consistent with applicable law and ethical standards of conduct, disclose your health information if Covenant, 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 Covenant 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.
For Worker’s Compensation.
Covenant may release your health information for worker’s compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above, Covenant will not disclose your health information other than with your written authorization. If you or your legal representative authorizes Covenant 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 Covenant maintains:

Right To Request Restrictions.
You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Covenant’s disclosure of your heath information to someone who is involved in your care or the payment of your care. However, Covenant is not required to agree to your request. If you wish to make a request for restrictions, please contact Director, Corporate Health Information.
Right To Receive Confidential Communications.
You have the right to request that Covenant communicate with you in a certain way. For example, you may ask that Covenant only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Director, Corporate Health Information.
Covenant 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 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 Director, Corporate Health Information. If you request a copy of your health information, Covenant may charge a reasonable fee for copying and assembling costs associated with your request as allowable by law.
Right To Amend Health Care Information.
If you or your legal representative believes that your health information records are incorrect or incomplete, you may request that Covenant amend the records. That request may be made as long as the information is maintained by Covenant. A request for an amendment of records must be made in writing to Director, Corporate Health Information Covenant 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 Covenant,
• the records you are requesting are not part of Covenant’s records,
• the health information you wish to amend is not part of the health information you or your legal representative are permitted to inspect and copy, or
• in the opinion of Covenant the records containing your health information are accurate and complete.
Right To An Accounting.
You or your legal representative have the right to request an accounting of disclosures of your health information made by Covenant for any reason other than for providing care and services to you, receiving payment for the services we provided to you, or as part of our normal business functions (treatment, payment or health operations.) The request for an accounting must be made in writing to Director, Corporate Health Information. The request should specify the time period for the accounting starting on April 14, 2003. Accounting request may not be made for periods of time in excess of six years. Covenant 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 legal representative have the right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact: Director, Corporate Health Information. You or your legal representative may also obtain a copy of the current version of Covenant’s Notice of Privacy Practices at its website, www.covenanthospice.org.

DUTIES OF COVENANT
Covenant is required by law to maintain the privacy of your health information and to provide to you and your legally appointed representative this Notice of its duties and privacy practices. Covenant is required to abide by terms of this Notices as may be amended from time to time. Covenant reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Covenant changes its Notice, Covenant will provide a copy of the revised Notice to you or your legally appointed representative. You or your legally appointed personal representative have the right to express complaints to Covenant and to the Secretary of Health and Human Services if you or your legally appointed representative believe that your privacy rights have been violated. Any complaints to Covenant should be made in writing to: Director, Corporate Health Information. Covenant 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
Covenant’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is Director, Corporate Health Information 5041 North 12th Ave, Pensacola, FL 32504. Telephone: (850)433-2155 or (800)541-3072.

EFFECTIVE DATE
This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Director, Corporate Health Information
5041 North 12th Ave
Pensacola, FL 32504
(850) 433-2155
(800) 541-3072