Notice of Privacy

Use and disclosure of health informationation
Cedar Valley Hospice 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 Cedar Valley Hospice has obtained your written consent. Cedar Valley Hospice 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. Cedar Valley Hospice may use your health information to coordinate care within Cedar Valley Hospice and with others involved in your care, such as your attending physician, members of Cedar Valley Hospice interdisciplinary team and other health care professionals who have agreed to assist Cedar Valley Hospice in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Cedar Valley Hospice also may disclose your health care information to individuals outside of Cedar Valley Hospice involved in your care including family members (as approved), clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals that the Hospice uses in order to coordinate your care.

To Obtain Payment. Cedar Valley Hospice may include your health information in invoices to collect payment from third parties for the care you may receive from Cedar Valley Hospice. For example, Cedar Valley Hospice may be required, by your health insurer, to provide information regarding your health care status so that the insurer will reimburse you or Cedar Valley Hospice. Cedar Valley 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. Cedar Valley Hospice may use and disclose health care information for its own operations in order to facilitate the function of the Cedar Valley Hospice and as necessary to provide quality care to all of the Cedar Valley Hospice’s patients. Health care operations include such activities as:

• 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 Cedar Valley Hospice.
• Memorializing patients through memorial services, placing keepsakes at funeral, and memorial listings with received donations.
• Fundraising for the benefit of Cedar Valley Hospice and certain marketing activities.

For example Cedar Valley Hospice may use your health information to evaluate its staff performance, combine your health information with other Hospice patients in evaluating how to more effectively serve all Hospice patients, disclose your health information to Hospice staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding a visit to you, or 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).

Cedar Valley Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and when you are in the Cedar Valley Hospice Home or in an inpatient facility. Cedar Valley 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.

Federal privacy rules allow Cedar Valley Hospice to use or disclose your health information without your consent or authorization for a number of reasons.

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

When There Are Risks to Public Health. Cedar Valley 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 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. Cedar Valley Hospice is required to notify government authorities if we believe a patient is the victim of dependent adult abuse, or neglect or child mal treatment. Cedar Valley Hospice will make disclosure of domestic violence only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities. Cedar Valley 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. Cedar Valley Hospice, however, will 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. Cedar Valley 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 tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Cedar Valley Hospice makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes. Cedar Valley Hospice 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 Cedar Valley Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct at the Hospice.
• In an emergency in order to report a crime.

To Coroners And Medical Examiners. Cedar Valley Hospice may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors. Cedar Valley 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. If necessary to carry out their duties, Cedar Valley Hospice may disclose your health information prior to and in reasonable anticipation, of your death.

For Organ, Eye Or Tissue Donation. Cedar Valley 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.

In the Event of A Serious Threat To Health Or Safety. Cedar Valley Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if Cedar Valley Hospice, 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 Cedar Valley Hospice 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.

Authorization to use or disclose health information
Other than is stated above, Cedar Valley Hospice will not disclose your health information other than with your written authorization. If you or your representative authorizes Cedar Valley Hospice 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 Cedar Valley Hospice 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 Cedar Valley Hospice’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Cedar Valley Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Official at 319-272-2002.
• Right to receive confidential communications. You have the right to request that Cedar Valley Hospice communicate with you in a certain way. For example, you may ask that Cedar Valley Hospice 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 your team’s Clincial Services Manager. Cedar Valley 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 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 Privacy Official at 319-272-2002. If you request a copy of your health information, Cedar Valley 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 believes that your health information records are incorrect or incomplete, you may request that Cedar Valley Hospice amend the records. That request may be made as long as the information is maintained by Cedar Valley Hospice. A request for an amendment of records must be made in writing to the Privacy Official. Cedar Valley 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 HIPAA Form #1 Page 4 of 5 your health information records were not created by Cedar Valley Hospice, if the records you are requesting are not part of Cedar Valley Hospice’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Cedar Valley 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 Cedar Valley Hospice for any reason other than for treatment, payment or health operations. The request for an accounting must be made in writing to the Privacy Official. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. Cedar Valley 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 have a 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 the Privacy Official at 319-272-2002.

Duties of the hospice
Cedar Valley 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. Cedar Valley Hospice is required to abide by terms of this Notice as may be amended from time to time. Cedar Valley Hospice 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 Cedar Valley Hospice changes its Notice, Cedar Valley Hospice will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative have the right to express complaints to Cedar Valley Hospice and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to Cedar Valley Hospice should be made in writing to the Executive Director. Cedar Valley 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
Cedar Valley Hospice’s contact person for all issues regarding patient privacy and your rights under the Federal privacy standards is the Privacy Official at:

2101 Kimball Avenue, Ste. 401,
P.O. Box 2880
Waterloo, IA 50704-2880
319-272-2002 Phone

Effective date
This Notice is effective April 14, 2003.

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