Notice of Privacy Policy

Alliance Hospice Care Notice of Privacy Practices

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This notice describes how medical information about you can be used and disclosed and how you can gain access to this information. please read it carefully. Effective Date: April 14, 2003; Revised: September 23, 2013

If you have any questions about this notice, please contact Alliance Hospice Care's privacy officer at 781-624-8828.

Our Pledge Regarding Your Health Information:

At Alliance Hospice Care, it is understood that medical information about you and your health is personal. Alliance Hospice Care is committed to protecting certain medical information about you (called "protected health information" or PHI) and complying with the privacy regulations established as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). "Protected Health Information" is information about you that may identify you and which is related to past, present or future physical or mental health conditions and related health care services.

The health care team creates a record of the care and services you receive at Alliance Hospice Care. This record is necessary to provide you with quality care and to comply with certain legal requirements. This notice applies to the records that your care has generated whether made by hospital personnel or your personal physician providing care to you at the hospital, or records received from other health care professionals in the context of providing your medical care. Your personal physician may have different policies regarding his/her use and disclosure of your medical information created and maintained in his/her office.

Our Legal Requirements

Legally, Alliance Hospice Care is required to:

• Take reasonable steps to ensure that your protected health information is kept private and secure;
• Give you a copy of this notice;
• Follow the terms of this notice that is currently in effect.

Who Will Follow This notice?

This notice describes Alliance Hospice Care's privacy practices. Alliance Hospice Care has entered into an organized health care arrangement with the physicians on the medical staff. As a result, the medical staff will also follow the terms of this Notice with respect to protected health information that they create or receive while providing services at the hospital. Alliance Hospice Care and the medical staff may share protected health information with one another as necessary to carry out treatment, payment or operations relating to this arrangement.

This notice also describes the privacy practices of:

• Any health care professional authorized to enter information into your hospital medical record.
• All departments and units of the hospital.
• Any members of the volunteer services that Alliance Hospice Care allows to help you while you are in the hospital.
• All employees, staff and other hospital personnel.
• All employees of the affiliates of Alliance Hospice Care.
• All affiliates, including Coastal Medical Associates.

How We May Use & Disclose Your Health Information

Alliance Hospice Care may use and disclose protected health information about you without your authorization for the following reasons:

• Treatment: Alliance Hospice Care may use protected health information about you to provide you with medical treatment or services. The hospital may disclose protected health information about you to doctors, nurses, technicians, students or other hospital personnel who are involved in your care. Your authorization is not needed for this.

Example: A physician treating you for a broken leg may need to know if you have diabetes. The pharmacy, laboratory and radiology departments may also need to know your diagnosis in order to coordinate all your tests and medications. Alliance Hospice Care may also provide information to people outside the hospital that will help coordinate your post-hospital care, such as a Visiting Nurse Association.

• Payment: Alliance Hospice Care may use and disclose protected health information about you to an insurance carrier or third party payer to verify coverage and to make sure that claims are billed and paid correctly. Your authorization is not required for this.

Example: Alliance Hospice Care may need to discuss a treatment you are scheduled to undergo to receive prior approval or authorization so that the insurance plan will reimburse Alliance Hospice Care for the procedure.

• Hospital Operations: Alliance Hospice Care may use your protected health information for administration, planning and quality assessment purposes, which are necessary to run the hospital and to make sure that all of our patients receive quality care. Your authorization is not required for this.

Example: Protected health information may be used to review treatment and services and to evaluate the performance of the staff caring for you.

• Appointment Reminders: Alliance Hospice Care may use or disclose limited protected health information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.
• Treatment Alternatives or New Services: Alliance Hospice Care may use and disclose protected health information to tell you about health-related options, services or alternatives available at Alliance Hospice Care that may be of interest to you.

Example: If you have been diagnosed with a particular disease and Alliance Hospice Care is offering a new treatment, support group or service, you may be notified of the new options available to you.

• Fundraising: Alliance Hospice Care may use limited information such as your name, address, phone number and dates of service in order to contact you in an effort to raise money for the hospital and its operations. The hospital also may disclose information to its affiliated fundraising foundation to allow the Foundation to reach you directly. You may opt out of these fundraising communications. If you do not wish to receive certain or all fundraising communications from the Alliance Hospice Care Charitable Foundation, please call the Foundation office at 781-624-8600 or email us at foundation@sshosp.org.

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When You May Disagree or Object to a Use or Disclosure

Alliance Hospice Care may use and disclose protected health information about you unless you disagree or object under the following circumstances:

• Hospital Directory: Unless you disagree or object, Alliance Hospice Care will include your name, location in the hospital, general health condition (e.g. good, fair) and religious affiliation in its inpatient directory. This information may be disclosed to anyone who asks for you by name or to clergy members. Your religious affiliation will only be made available to clergy members.
• Individuals Involved In Your Care: Alliance Hospice Care may release protected health information to a family member or to another person identified by you when you are present for, or available prior to, the disclosure. If your agreement is obtained and you do not (or it can be reasonably inferred that you do not) object to the disclosure, the hospital may release information as described. If your consent can not be obtained because you are incapacitated or are in an emergency situation, professional judgment will be used to determine whether disclosure of protected health information is in your best interest.

Example: Unless Alliance Hospice Care has a reason to believe you would not want them notified, Alliance Hospice Care may contact your family or a close friend in the event of an emergency to disclose your condition and location in the hospital. Alternatively, in cases of suspected abuse, neglect or endangerment, Alliance Hospice Care may elect not to disclose information to your family or a personal representative if there is reason to believe that providing the information may put you at risk.

• Disaster Plan or Terrorist Attack Notification: Unless you disagree or object, Alliance Hospice Care may disclose protected health information to those assisting in disaster relief so that your family can be notified about your location and condition.

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Special Situations

There are other special situations that allow Alliance Hospice Care to use or disclose protected health information about you without your authorization. These are:

• Research: Under certain conditions, Alliance Hospice Care may use and disclose protected health information about you for research without your prior authorization. All research projects, however, are subject to a special review process. Before any information is released, a review board must approve the project, although Alliance Hospice Care may disclose medical information about you to people preparing to conduct a research project, such as to help them look for patients with specific medical needs, so long as the medical information they review does not leave the hospital. You will almost always be asked for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or if that researcher will be involved in your care at the hospital.

Example: A research project may compare the health and recovery of patients who receive one medication as opposed to those who receive a different medication for the same condition.

• Organ and Tissue Donation: If you are a registered organ or tissue donor or if your family authorizes organ or tissue donation on your behalf, or if you are a proposed organ or tissue recipient, Alliance Hospice Care may release protected health information to organizations that handle organ and tissue procurement in order to help facilitate a donation/transplant.
• As Required By Law: Alliance Hospice Care will disclose protected health information about you when required by local, state or federal law.

Example: Alliance Hospice Care is required to report births and deaths to the state and must report certain infectious diseases to the Department of Public Health.

• To Avert A Serious Threat To Health or Safety: Alliance Hospice Care may use or disclose protected health information about you when necessary to prevent a serious threat to your health and safety, the health and safety of another, or the public. Such disclosure would be only to a person or agency involved in the effort to prevent the perceived threat or to the identified individual or individuals believed to be at risk.
• Military and Veterans: If you are a member of the military, Alliance Hospice Care may release protected health information about you as required by the military command authorities. Alliance Hospice Care may release protected health information about foreign military personnel to the appropriate foreign military authorities.
• Workers' Compensation: Alliance Hospice Care may release information about you for Workers' Compensation or similar programs.
• Public Health Risks: Alliance Hospice Care has legal obligations to disclose protected health information about you for certain public health reasons. The hospital has no choice in this matter.

Example: Examples include, but are not limited to, the reporting of births/deaths, elder/child abuse or neglect, reactions to medications, recalls of products, information to assist in preventing and controlling disease or injuries, to notify a person who has been exposed to a disease or who may be at risk for contracting or spreading a disease.

• Health Oversight Activities: Alliance Hospice Care may disclose protected health information to a health oversight agency in connection with an audit, inspection, investigation, or license proceeding to ensure compliance with government rules, including those that apply to Medicare and Medicaid.
• Lawsuits and Disputes: If you are involved in a lawsuit/dispute, Alliance Hospice Care may disclose information about you in response to a court order or other valid legal process (e.g. subpoena, summons). The hospital may also disclose protected health information about you to someone else involved in the lawsuit/dispute according to the legal process.
• Law Enforcement: Alliance Hospice Care may be required or permitted to release protected health information if asked to do so by a law enforcement agent or organization with the appropriate court order, subpoena, warrant or summons.

Example: Alliance Hospice Care may release protected health information to (i) identify a suspect, fugitive or material witness; (ii) report a death that Alliance Hospice Care believes to be the result of criminal conduct; (iii) disclose criminal conduct which occurred in the hospital or on hospital property; or (iv) in an emergency to report a crime, the location of the crime or victims, and the identity and description of a person believed to have committed the crime.

• In The Event Of Your Death: Alliance Hospice Care may release information to a coroner/medical examiner in order to assist in identifying you or determining the cause of your death. The hospital may disclose protected health information to a funeral director to assist him/her in performing his/her duties.
• National Security and Intelligence Activities: With proper court order, Alliance Hospice Care may disclose protected health information about you to authorized federal officials, counterintelligence and other national security activities authorized by law.
• Protective Services For The President and Others: With the proper court order, Alliance Hospice Care may disclose protected health information about you to authorized federal officials so that they may provide protection to the President, and other authorized persons or foreign heads of state.
• Inmates: If you are an inmate of a correctional institution or under the custody of law enforcement officials, Alliance Hospice Care may release protected health information about you to the correctional institution or law enforcement officials to enable them to provide you with adequate care, to protect your health and safety and the safety of others, and to provide for the safety and security of the correctional institution.
• When The Patient Is A Minor: Special laws apply to the use and disclosure of protected health information about minors. If the patient is a minor (under 18 years of age), patient information cannot be released without the consent of a parent or legal guardian, unless the minor is deemed to be emancipated. Once a minor reaches the age of 18, however, protected health information can no longer be released to a parent without the patient's written consent.

A minor is deemed "emancipated" and has control over his/her own medical records if the minor:

– Is married, widowed or divorced;
– Has a child;
– Is a member of the armed forces;
– Is pregnant or believes herself to be pregnant (this only applies to the records related to the pregnancy, pregnancy testing, or pregnancy termination);
– Is living away from his/her parents and managing his/her own finances; or
– Believes he/she has come in contact with a dangerous disease as defined by the Department of Public Health (this applies only to those records related to the suspected dangerous disease).

Uses & Disclosures That Require Your Written Permission:

If Alliance Hospice Care wishes to use or disclose protected health information about you for any reason other than those reasons listed above, the hospital will likely be required to obtain your written permission. For example, we are not permitted to provide your protected health information to any other person or company for marketing to you of any products or services, or to receive payment in exchange for marketing communications, without your written permission. We are also not permitted to receive payments for the sale of your protected health information without your written permission. There are exceptions to this general rule, including when the purpose of the payment is for (i) public health activities; (ii) research purposes (if the price charged reflects the cost of preparation and transmittal of the information); (iii) your treatment; (iv) performance of services by a business associate on our behalf; or (v) providing you with a copy of your protected health information. You have the right to revoke this written permission.

If you revoke your permission, the hospital will no longer use or disclose your protected health information about you for the reasons covered by your written authorization. The hospital is unable to take back any disclosures already made with your authorization and is required to retain a record of all care provided to you.

Your Rights Regarding Your Health Information

• Right To Inspect and Copy: You have the right to inspect and have copied protected health information that may be used to make decisions about your medical care. This includes medical and billing records but does not include psychotherapy notes. If the hospital maintains this information electronically, you may request that this information be given to you in electronic form. To inspect and have copied this information, you must submit your request in writing to the Director of Health Information Management. You must present valid picture identification upon presenting yourself to the HIM Department. If you request a copy of this information, Alliance Hospice Care may charge a reasonable fee for copying, mailing, or other supplies associated with your request, including costs of any portable electronic media (like CDs or flash drives) used to provide you with electronic copies.Alliance Hospice Care may deny your request under certain circumstances. If you are denied access to your records, you may send a written request to the Director of Health Information Management to review the denial. Another licensed health care professional or health care team chosen by the hospital will review your request and the reasons for the denial. The person who denied your request will not be involved in the review process. The hospital will comply with the outcome of the review.

• Right To Request An Amendment To Your Records: If you feel the protected health information Alliance Hospice Care has about you is incorrect or incomplete, you have the right to request an amendment at any time. Your request for an amendment must be made in writing to the Director of Health Information Management and must state the reason for the requested amendment. The hospital may deny your request if (i) you ask to amend information that was not created by Alliance Hospice Care, (ii) it is not part of the protected health information kept for or by Alliance Hospice Care, (iii) it is not part of the information which you are permitted to inspect or copy, or (iv) Alliance Hospice Care believes the information is accurate and complete. If your request is denied, you have the right to send a letter of objection to the Director of Health Information Management that will then be attached to your permanent medical record along with any written rebuttal that the hospital feels is necessary.
• Right To Request An Accounting Of Disclosures: You have a right to request a list of various disclosures that Alliance Hospice Care has made of your protected health information. Alliance Hospice Care is not required to keep a list of any uses or disclosures for treatment, payment or operations purposes or for any uses or disclosures that are made after obtaining your written authorization.To request an accounting of disclosures, you must submit a written request to the Director of Health Information Management. Your request must state a time period that does not go back more than six (6) years and that does not include dates prior to April 14, 2003. Your request should indicate in what form you want the list (e.g. on paper or electronically). The first list you request within any twelve (12) month period will be provided free of charge. The hospital may charge you a reasonable fee for the costs incurred in producing any additional lists. Alliance Hospice Care will notify you of the charges and you may choose to modify or withdraw your request before any costs are incurred.
• Right To Request Restrictions On The Use & Disclosure Of Your Information: You have the right to request a limit on the protected health information Alliance Hospice Care uses or discloses for treatment, payment or operations purposes, including the right to limit information given to your health plan related to services you paid for in-full as out-of-pocket costs. You may also request a limit on the information provided to someone you have identified as a person to be informed about your medical condition or the payment for your care (e.g. family member, friend or attorney). Alliance Hospice Care is not required to agree to your request. If the request is agreed to, the hospital will comply with your request, unless the information is required to provide you with emergency care. To request a restriction, you must send a written request to the Director of Health Information Management that states (i) the information you want limited, (ii) whether you want to limit Alliance Hospice Care's use, disclosure or both, and (iii) to whom you want the limits to apply (e.g. child or spouse).

Example: If you would like a family member to be informed about your medical care, you may restrict the information provided to include only information relevant to a particular procedure or hospitalization and not your entire medical record.

• Right to Request Non-Disclosure of Information to Health Plans for Self-Pay Items or Services: If you pay out-of-pocket and in full for health care items or services, prior to the time the items or services are provided to you, and request that Alliance Hospice Care not disclose information about those health care items or services to your health plan, Alliance Hospice Care will honor your request, unless the disclosure is otherwise required by law. In order for Alliance Hospice Care to implement your request to restrict health plan disclosures for self-pay services, you must obtain the proper form from the Alliance Hospice Care Patient Access Services Department or (781) 624-4329 and submit the completed form to the Patient Access Services Department, on or before the date of service. Alliance Hospice Care may not be able to honor your request if you wait until care has started to make a request for a restriction on disclosures to your health plan. If the payment you make is not honored for some reason (e.g. a check bounces), Alliance Hospice Care will make a reasonable effort to contact you to obtain an alternative form of payment. However, if that effort is unsuccessful, Alliance Hospice Care may proceed to bill your health plan for the items or services that were provided. This restriction on disclosures only applies to items or services furnished by Alliance Hospice Care. You should talk with the other providers involved in your care (e.g. physicians, pharmacists) to discuss your desire to restrict the disclosure of information they may otherwise submit to your health plan.
• Right To Request Confidential Communications or Communications in a Certain Way: You have the right to request that Alliance Hospice Care communicate with you about medical matters in a certain way or at a certain location in order to better maintain your privacy. To request that the ways in which you are contacted are limited, you must send a written request to the Director of Health Information Management. You will not be asked the reason for your request and the hospital will honor all reasonable requests (as defined by Alliance Hospice Care). The request must specify how or where you wish to be contacted.

Example: You may ask Alliance Hospice Care to contact you only at work or at a particular telephone number, or by mail in plain white envelopes.

• Right To Receive Notifications of Data Breach: You have the right to be notified if there is a breach of any of your unsecured protected health information that we hold or control. Protected health information is "unsecured" if it is not protected by a technology or methodology that makes it unreadable, like encryption. The notice must be made within 60 days from when we become aware of the breach. The notice must include: (i) a brief description of the breach, including the date of breach and discovery; (ii) a description of the types of unsecured protected health information disclosed or misappropriated during the breach; (iii) the steps you can take to protect your identity; (iv) a description of our actions to investigate the breach and mitigate harm now and in the future; and (v) contact procedures (including a toll-free telephone number) for affected individuals to find additional information. We must notify you in writing by first class mail (unless you have opted for electronic communications with us). However, if we have insufficient contact information for you, an alternative notice method (posting on website, broadcast media, etc.) may be used. If a breach affects more than 500 individuals, we must immediately notify the federal government (the U.S. Department of Health and Human Services) after which the government will post our name on its internet website. Additionally, we may be required to publish a notice in a prominent media outlet in each state or jurisdiction where more than 500 individuals' unsecured protected health information has been breached. For breaches involving fewer than 500 individuals, we are required to maintain a log of such breaches and submit this information annually to the federal government. Finally, we may telephone you if we reasonably believe there is a possibility of imminent misuse of your unsecured protected health information; however, such telephone contact will not substitute for our written notice obligations.
• Right to Opt Out of Fundraising Communications: You have the right to opt out from communications regarding our fund-raising programs and events.
• Right To A Copy Of This Notice: You have a right to receive a paper copy of this notice. You may ask for additional copies of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of this notice, please ask the patient registration staff assisting you or call the Privacy Officer at (781) 624-8828.

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Changes to this notice:

Alliance Hospice Care reserves the right to change this notice without notification. The hospital reserves the right to make the revised notice effective for protected health information already collected about you, as well as any information received in the future. The hospital will post a copy of the current notice in all hospital admitting areas.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with either the hospital or with the Office of Civil Rights. The contact information is:

To file a complaint with Alliance Hospice Care, contact the Privacy Officer at:

Alliance Hospice Care
Privacy Officer
55 Fogg Road,
Mailbox #82
South Weymouth, MA 02190-2455

Tel: 781-624-8828
Fax: 781-624-5140

Contact the Director of Health Information Management at:

Alliance Hospice Care
Director of Health Information Management
55 Fogg Road,
Mailbox #55
South Weymouth, MA 02190-2455

Tel: (781) 624-8233
Fax: (781) 624-3916

For Alliance Hospice Care Home Care Division medical record requests, contact the Director of Administrative Operations for SSH Home Care Division at (781) 624-7821.

To file a complaint with the Office of Civil Rights, use the information provided here:

Office of Civil Rights
Regional Manager
Government Center
JFK Federal Building
Room 1875
Boston, MA 02203-0002

Regional Manager Tel: 617- 565-1340
Government Center Fax: 617- 565-3809
TDD: 617- 565-1343

All complaints must be submitted in writing.

You will not be penalized in any way for filing a complaint, nor will your hospital care be compromised in any way.

Alliance Hospice Care, LLC does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by Alliance Hospice Care, LLC directly or through a contractor or any other entity with which Alliance Hospice Care, LLC arranges to carry out its programs and activities.

Alliance Hospice Care, LLC is an equal opportunity employer

TDD or State Relay number: (617) 402-5202