Georgia Mountains Hospice 09/2013
HIPAA Notice of Privacy Practices
Georgia Mountains Hospice understands that your health information is highly personal and we are committed to safeguarding your
privacy. Please read this Notice of Privacy Practices thoroughly. It describes how Georgia Mountains Hospice will use and disclose your
Protected Health Information (PHI). The Notice refers to Georgia Mountains Hospice by using the terms “us”, “we,” or “our.”
I. Georgia Mountains Hospice (“Provider”) Privacy Notice
This notice describes how we secure the Protected Health Information (PHI) that we have about you that relates to
your medical information or personal health information. Protected Health Information refers to medical information
and may include other information about you, including demographic information, that may identify you and that
relates to your past, present or future physical or mental health or condition and related health care services.
This Notice of Privacy Practices describes how we may use and disclose to others your Personal Health Information
to carry out payment or healthcare operations and for other purposes that are permitted or required by law. It also
describes your rights to access and control of your Personal Health Information.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any
time. The new notice will be effective for all Personal Health Information that we maintain at that time. This notice may
also be revised if there is a material change to the uses or disclosures of Personal Health Information, your rights, our
legal duties, or other privacy practices stated in this notice. Within 60 days of a material revision to this notice we will
provide you with a copy of the revised notice. Additionally, upon your request, we will provide you with any revised
Notice of Privacy Practices by calling us at 1-800-692-7199 and requesting that a revised copy be sent to you in the mail.
Federal and state laws provide special protections for certain kinds of personal health information (mental health records,
alcohol and drug treatment records, communicable disease records or genetic test records) and, therefore: calls for specific
authorizations from you to disclose information to third parties. When your personal health information falls under these
special protections, we will secure the required written authorization, pursuant to a valid court order or as otherwise
required by law.
II. How We Will Use And Disclose Your PHI
To Provide Treatment.
Georgia Mountains Hospice may use and disclose your PHI to coordinate care within the Georgia Mountains Hospice
program and with others involved in your care, such as your attending physician, members of Georgia Mountains
Hospice interdisciplinary team and other health care professionals who have agreed to assist Georgia Mountains
Hospice in coordinating your care. Georgia Mountains Hospice also may disclose your health care information to
individuals outside of the hospice program which are involved in your care, including, family members, clergy whom
you have designated, pharmacists, suppliers of medical equipment and/or other health care professionals. For
example, we may disclose your PHI to a pharmacy to fill a prescription or to a laboratory to order a blood test. We
may also disclose your PHI to another physician who may be treating you or consulting with us regarding your care.
To Obtain Payment.
Georgia Mountains Hospice may also use and disclose your PHI, as needed, to obtain payment for services that we
provide to you. This may include certain communications to your health insurer or health plan to confirm (1) your
eligibility for health benefits, (2) the medical necessity of a particular service or procedure, or (3) any prior
authorization or utilization review requirements. We may also disclose your PHI to another Provider involved in your
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care for the other Provider's payment activities. For example, this may include disclosure of demographic information
to another physician practice that is involved in your care, or to a hospital where you were recently hospitalized, for
payment purposes.
To Perform Health Care Operations.
Georgia Mountains Hospice may also use or disclose your PHI, as necessary, to carry on our day-to-day health care
operations and to provide quality care to all of our Patients. The PHI disclosed will be imparted on a "need to know"
basis. These health care operations may include such activities as: quality assessment and performance improvement
activities; professional review and performance evaluation; Activities designed to improve health or reduce health
care costs; health professional training programs, including those in which students, trainees, or practitioners in health
care learn under supervision; accreditation; certification; licensing or credentialing activities; compliance reviews and
audits; defending a legal or administrative claim; business management development; and other administrative
activities. In certain situations, Georgia Mountains Hospice may also disclose your PHI to another health care
Provider or health plan to conduct their own particular health care operation requirements.
To Contact You.
To support our treatment, payment and health care operations, Georgia Mountains Hospice may also, from time to
time, contact you at home, either by telephone or mail, (1) to remind you of an upcoming activity date, (2) for
bereavement activities or (3) to ask you to return a call to Georgia Mountains Hospice unless you ask us, in writing, to
use alternative means to communicate with you regarding these matters. We may also contact you by telephone to
coordinate interdisciplinary visits, inform you of specific test results or treatment plans. Your signature on this
HIPAA Notice of Privacy Practices implies your permission.
Business Associates.
Georgia Mountains Hospice provides some services through contracts with business associates, included,
but not limited to: accountants, consultants, and attorneys, so that they can perform the tasks that we have
assigned to them. To protect your health information, we require the business associate to appropriately
safeguard health information about you.
To Be In Contact With Your Family or Friends.
Additionally, Georgia Mountains Hospice may also disclose certain of your PHI to your designated family
member/primary caregiver or another relative, a close personal friend, or any other person specified by you, but only
if the PHI is directly related (1) to the person's involvement in your treatment or related payments, or (2) to notify the
person of your physical location or a sudden change in your condition. Although you have a right to request
reasonable restrictions on these disclosures, Georgia Mountains Hospice will only be able to grant those restrictions
that are reasonable and not too difficult to administer, none of which would apply in the case of an emergency.
According to Laws That Require or Permit Disclosure.
Georgia Mountains Hospice may disclose your PHI when we are required or permitted to do so by any federal, state
or local law, as follows:
1. When There Are Risks to Public Health.
Georgia Mountains Hospice may disclose your PHI to (1) report disease, injury or disability; (2) report vital
events such as births and deaths; (3) conduct public health activities; (4) collect and track FDA-related events and
defects; (5) notify appropriate persons regarding communicable disease concerns; or (6) inform employers about
particular workforce issues.
2. To Report Suspected Abuse, Neglect Or Domestic Violence.
Georgia Mountains Hospice may notify government authorities if we believe that a Patient is the victim of abuse,
neglect or domestic violence, but only when specifically required or authorized by law or when the Patient agrees
to the disclosure.
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3. To Conduct Health Oversight Activities.
Georgia Mountains Hospice may disclose your PHI to a health oversight agency for activities including audits;
civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary
actions; or other activities necessary for appropriate oversight, but we will not disclose your PHI if you are the
subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.
4. In Connection With Judicial and Administrative Proceedings.
Georgia Mountains Hospice may disclose your PHI in the course of any judicial or administrative proceeding in
response to an order of a court or administrative tribunal. In certain circumstances, we may disclose your PHI in
response to a subpoena if we receive satisfactory assurances that you have been notified of the request or that an
effort was made to secure a protective order.
5. For Law Enforcement Purposes.
Georgia Mountains Hospice may disclose your PHI to a law enforcement official to, among other things, (1)
report certain types of wounds or physical injuries, (2) identify or locate certain individuals, (3) report limited
information if you are the victim of a crime or if your health care was the result of criminal activity, but only to
the extent required or permitted by law.
6. To Coroners, Funeral Directors, and for Organ Donation.
Georgia Mountains Hospice may disclose your PHI to a coroner or medical examiner for identification purposes,
to determine cause of death or for the coroner or medical examiner to perform other duties. We may also disclose
PHI to a funeral director in order to permit the funeral director to carry out their duties. PHI may also be disclosed
for organ, eye or tissue donation purposes.
7. In the Event of a Serious Threat to Health or Safety, or For Specific Government Functions.
Georgia Mountains Hospice may, consistent with applicable law and ethical standards of conduct, use or disclose
your PHI if we believe, in good faith, that such use or 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, or for certain other specified
government functions permitted by law.
8. Marketing.
Georgia Mountains Hospice must obtain your written authorization to use and disclose health information about
you for most marketing purposes.
9. For Worker’s Compensation.
Georgia Mountains Hospice may disclose your PHI to comply with worker‘s compensation laws or similar
programs.
10. Correctional Institutions.
If you are an inmate of a correctional institution or under the custody of a law enforcement official, Georgia
Mountains Hospice may use or disclosure health information about you. Such health information will be
disclosed to the correctional institution or law enforcement official when necessary for the institution to provide
you with health care and to protect the health and safety of others.
11. Information Not Personally Identifiable.
Georgia Mountains Hospice may use or disclose health information about you in ways that do not personally
identify you or reveal who you are.
12. With Your Prior Express Written Authorization.
Other than as stated above, Georgia Mountains Hospice will not disclose your PHI, or more importantly, your
Special PHI, without first obtaining your express written authorization. Please note that you may revoke your
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authorization in writing at any time except to the extent that we have taken action in reliance upon the
authorization.
III. Your Individual Rights Concerning Your PHI
A. The Right to Inspect and Copy Your PHI.
You may inspect and obtain a copy of your PHI that Georgia Mountains Hospice has created or received as we
provide your treatment or obtain payment for your treatment. A copy may be made available to you either in paper
or electronic format if we use an electronic health format. Under federal law, however, you may not inspect or copy
the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil,
criminal, or administrative action or proceeding; and PHI that is subject to a law prohibiting access. Depending on
the circumstances, you may have the right to request a second review if our Privacy Officer denies your request to
access your PHI. Please note that you may not inspect or copy your PHI if your physician believes that the access
requested is likely to endanger your life or safety or that of another person, or if it is likely to cause substantial harm
to another person referenced within the information. As before, you have the right to request a second review of this
decision. To inspect and copy your PHI, you must submit a written request to the Privacy Officer. Georgia
Mountains Hospice may charge you a fee for the reasonable costs that we incur in processing your request.
B. The Right to Request Restrictions on How We Use and Disclose Your PHI.
You may ask Georgia Mountains Hospice not to use or disclose certain parts of your PHI but only if the request is
reasonable. For example, if you pay for a particular service in full, out-of-pocket, on the date of service, you may ask
us not to disclose any related PHI to your health plan. You may also ask us not to disclose your PHI to certain family
members or friends who may be involved in your care or for other notification purposes described in this Privacy
Notice, or how you would wish us to communicate with you regarding upcoming appointments, treatment alternatives
and the like by contacting you at a telephone number or address other than at home. Please note that we are only
required to agree to those restrictions that are reasonable and which are not too difficult for us to administer. We will
notify you if we deny any part of your request, but if we are able to agree to a particular restriction, we will
communicate and comply with your request, except in the case of an emergency. Under certain circumstances,
Georgia Mountains Hospice may choose to terminate our agreement to a restriction if it becomes too burdensome to
carry out. Finally, please note that it is your obligation to notify us if you wish to change or update these restrictions
by contacting the Privacy Officer directly.
C. Right to Request Alternative Method of Communication.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain
location. Your request must be in writing. We will accommodate all reasonable requests.
D. The Right to Request Amendments to Your PHI.
You may request that your PHI be amended so long as it is a part of our official Patient Record. All such requests
must be in writing and directed to our Privacy Officer. In certain cases, we may deny your request for an amendment.
If Georgia Mountains Hospice denies your request for amendment, you have the right to file a statement of
disagreement with us and we may respond to your statement in writing and provide you with a copy.
E. Right to Revoke Authorization.
You have the right to revoke your authorization to use or disclose health information, except to the extent that action
has been taken in reliance upon your authorization. Your request must be in writing
F. The Right to Receive an Accounting.
You have the right to request an accounting of those disclosures of your PHI that we have made for reasons other
than those for treatment, payment and health care operations, which are specified in Section II (A-C) above. The
accounting is not required to report PHI disclosures (1) to those family, friends and other persons involved in your
treatment or payment, (2) that you otherwise requested in writing, (3) that you agreed to by signing an authorization
form, or (4) that we are otherwise required or permitted to make by law. As before, your request must be made in
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writing to our Privacy Officer. The request should specify the time period, but please note that we are not required to
provide an accounting for disclosures that take place prior to September 01, 2007. Accounting requests may not be
made for periods of time in excess of six years. We will 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.
G. The Right to Receive Notice of a Breach.
You have the right to receive written notice in the event Georgia Mountains Hospice learns of any unauthorized
acquisition, use or disclosure of your PHI that was not otherwise properly secured as required by HIPAA. We will
notify you of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered.
H. Right to Opt Out of Fundraising Communications.
Georgia Mountains Hospice may contact you for fundraising purposes. You have the right to opt out of receiving any
of these communications.
I. Right to Copy of Notice of Privacy Practices.
You have the right to a paper copy of our Notice at any time. Please contact Georgia Mountains Hospice’s Privacy
Officer at the address or phone listed below to obtain a copy.
J. The Right to File a Complaint.
You have the right to contact the Georgia Mountains Hospice Privacy Officer at any time if you have questions,
comments or complaints about our privacy practices or if you believe we have violated your privacy rights. You also
have the right to contact our Privacy Officer or the Department of Health and Human Services’ Office for Civil Rights
in Atlanta, GA regarding these privacy matters, particularly if you do not believe that we have been responsive to
your concerns. We urge you to contact our Privacy Officer if you have any questions, comments or complaints, either
in writing or by telephone as follows:
Georgia Mountains Hospice
70 Caring Way
Jasper, GA 30143
706-253-4100
1-800-692-4199
gmh@ellijay.com
Attn: Privacy Officer
EFFECTIVE DATE This Notice is effective April 14, 2003 Amended date: September 19, 2013
_________________________________________ _______________________________________ ________________________
Patient’s Name / Medical Record # (Please Print) Patient’s Signature Date
_________________________________________ _______________________________________ ________________________
Legal Representative’s Name (Please Print) Legal Representative’s Signature Date
_________________________________________ _________________________________________________________________
Relationship Reason Patient Unable to Sign
_________________________________________ _______________________________________ ________________________
Hospice Representative Name (Please Print) Hospice Representative’s Signature Date
