Notice of Privacy Practices

Hospice of Amador & Calaveras



Hospice of Amador & Calaveras (“Hospice”) may use your health information for purposes of providing you treatment, obtaining payment for your care, and conducting health care operations. Hospice has established policies to guard against unnecessary use and disclosure of your protected health information.

Thefollowingisasummary of thecircumstances underwhichandpurposes forwhichyourhealthinformationmay be used and disclosed.

To Provide Treatment: Hospice may use your health information to coordinate care within Hospice and with others involved in your care, such as your attending physician, members of the Hospice interdisciplinary team, and other healthcare professionals who have agreed to assist Hospice in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Hospice may also disclose your health information to individuals outside Hospice involved in your care including designated family members, pharmacists, suppliers of medical equipment, or other health care professionals.

To Obtain Payment: Hospice may use and disclose your protected health information to other providers so they may bill and collect payment for treatment and services they provided to you. For example, your health insurer may require information regarding your health status so that the insurer will reimburse Hospice. Your insurer may also require that prior approval for your care be obtained with an explanation of need for hospice care and the services that will be provided to you.

To Conduct Health Care Operations: Hospice may use and disclose health information for its own operations in order to facilitate the function of Hospice and as necessary to provide quality care to all of Hospice’s patients. Health care operations include such activities as:

•          Quality assessment and improvement activities

•          Activities designed to improve health or reduce health care costs

•          Protocol development, case management and care coordination

•          Professional review and performance evaluation

•         Training programs including those in which students, trainees or practitioners in healthcare learn under supervision

•         Training of non-healthcare professionals

•         Accreditation, certification, licensing or credentialing; activities

•         Review and auditing, including compliance reviews, medical reviews, legal services and compliance program

•         Business planning and development including costs management and planning related analyses and formulary development

•         Business management and general administrative activities of Hospice

•         Resolving grievances within Hospice

•         Complying with this notice and with applicable laws

•         Fundraising for the benefit of Hospice

For example, Hospice may use your health information to evaluate 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, or contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).

For Appointment Reminders: Hospice may use and/or disclose your health information to contact you as a reminder that you have an appointment for a home visit. Contact could be through various means (e.g. telephone, answering machine message, e-mail).

For Treatment Alternatives: Hospice may use and/or disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

For Fundraising Activities: Certain information about you (e.g. name, address, phone number, dates you received care) may be used in order to contract you or your family to raise money for Hospice. If you or your family does not want to be contacted, notify the Hospice Privacy Officer at the address given below and request that your information be removed

fromourcontact lists.Your requestmayinclude removal of yourinformationfromaspecific fundraising campaign or from allfundraising campaigns. Your decision notto be contacted willnotaffect your treatment or the payment required of you.And,you havetherightto changeyour decisionat anytimeandbe added backtothecontactlists.

For Business Associates: There are some services provided in our organization through contracts with business associates. For example, we may use a copy service to make copies of your medical record. When we hire companies to perform these services, we may disclose your health information to these companies so they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your protected health information.

For Individuals Involved in Your Care or Payment for Your Care: Hospice may share your health information with a family member or other person identified by you who is involved in your care or payment for your care. We may tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting in disaster relief efforts so that your family can be notified about your condition and location. If you do not want information about you released to those involved in your care, please notify the Hospice Privacy Officer at the address given below. Following an individual’s death, we may continue to disclose certain health information to family, friends, and others who were involved in the care or payment for care of the individual. Additionally, the use and disclosure of an individual’s health information is only limited to a period of 50 years following their death.

Federal privacyrulesallowthe agencytouseordisclose your healthinformation withoutyour consent orauthorization in a number of special circumstances

When Legally Required: Hospice will disclose your health information when legally required to do so by any Federal, State or local law.

When There are Risks to Public Health: Hospice may disclose your health information for public activities and purposes in order to:

  • Preventor 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
  • 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
  • Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease
  • Notify an employer about an individual who is a member of the work force as legally required

To Report Abuse, Neglect or Domestic Violence: Hospice is allowed to notify government authorities if Hospice believes a patient is the victim of abuse, neglect or domestic violence. Hospice will make this disclosure when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities: Hospice may disclose your health information to a health oversight agency for activities including audits, civil administration or criminal investigations, inspections, licensure or disciplinary action. Hospice, 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: Hospice may disclose your health information in the course of any judicial or administrative proceeding in response to an order of the 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 Hospice makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes: As permitted or requested by State law, Hospice may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

  • As required by law for reporting 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 Hospice has a suspicion that your death was the result of criminal conduct, including criminal conduct at Hospice
  • In an emergency to report a crime

For Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

To Coroners and Medical Examiners: 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: 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, Hospice may disclose your health information prior to and in anticipation of your death.

Facilitating Patient Request for Organ, Eye or Tissue Donation: Hospice may use or disclose your health information to organ procurement organizations or other entities engaged in procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes: Under certain circumstances, your health information may be used or disclosed for research purposes. Before Hospice discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. We may, however, use medical information about you in preparing to conduct a research project, for example, to look for patients with specific needs as long as the medical information reviewed does not leave our entity.

In the Event of a Serious Threat to Health or Safety: Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if Hospice, in good faith, believes that such disclosure is necessary to prevent or lessen a serious or imminent threat to your health, safety, or to the health and safety of the public.

For Specified Government Functions: In certain circumstances, the Federal Regulations authorize 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 for determinations and inmates and law enforcement custody.

For Workers’ Compensation: Hospice may release your health information for workers’ compensation or similar programs.


Other than stated above, Hospice will not disclose your health information other than with your written authorization. If you or your representatives authorize Hospice to use or disclose your health information, you may revoke that authorization in writing at any time. If you revoke your permission, Hospice will no longer use or disclose your health information for the reasons covered by your written authorization. Hospice is unable to take back any disclosures already made with your permission. Hospice is required to retain records of the care provided to you. Specific cases that require written authorization are:

Marketing: Authorization is required before we may use your health information for marketing purposes. If Hospice is to receive remuneration in connection to the marketing, Hospice must inform you of such as part of the authorization information.

Sale of Health Information: The sale of your health information is allowed for certain purposes. Authorization is required before we may sell your health information. If Hospice is to receive remuneration in connection with the sale, Hospice must inform you of such as part of the authorization process.

Research: For research purposes, certain uses of your de-identified health information are permitted without your authorization. In cases where the use does not allow de-identification, your authorization is required. Strict rules exist to govern such use.


You have the following rights regarding your health information that is maintained by Hospice:

Right to Request Restrictions: You may request restrictions on certain uses and disclosure of your health information. You have the right to request a limit on Hospice’s disclosure of your health information to someone who is not involved in your care or the payment for your care. However, Hospice is not required to agree to your request in all cases. You may request and Hospice must comply with a request for restriction not to disclose your health information to your health plan where you have paid for the treatment fully out-of-pocket. However, there are conditions and exceptions. If you wish to make a request for restrictions, please contact the Hospice Privacy Officer to obtain a written request form.

Right to Receive Confidential Communication: You have the right to request that Hospice communicate with you in a certain way. For example, you may ask that Hospice only conduct communications pertaining to your health information with you privately, with no other family members present. If you wish to receive confidential communication, contact the Hospice Privacy Officer. Hospice will not ask you to 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/or receive: a copy of your health information. If you request an electronic copy of your health record, Hospice will provide you a copy of the portion of your record that we maintain electronically in the form or format you request, if it is readily producible. Any portion of your record that we do not maintain electronically will be provided to you in a paper format. You may request us to “transmit” the electronically maintained health information to a third party, provided that third party is clearly identified along with the desired mode of delivery. A request to inspect or receive a copy of records containing your health information must be made in writing to the Hospice Privacy Officer. If you request a copy of the information, Hospice may charge a fee for the costs of copying, mailing, electronic media, or other supplies associated with your request. Hospice will respond to you within 30 days of receiving your written request. There are certain situations in which Hospice is not required to comply with your request. Under these circumstances, Hospice will respond in writing stating why your request will not be granted and describing any rights you have to request a review of the denial.

Right to Amend Health Care Information: You or your representative have the right to request that Hospice amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by Hospice. A request for an amendment of records must be made in writing to the Hospice’s Privacy Officer. Hospice may deny the request if it is not in writing or does not include a reason for the amendment. The request may also be denied if your health records were not created by Hospice, if the records you are requesting are not part of 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 Hospice, the records containing your health information are accurate and complete.

Right to An Accounting of Disclosures: You have the right to receive a written list of certain disclosures Hospice has made of your protected health information. You may ask for disclosures to be made up to six (6) years before your request. Hospice is required to provide a listing of all disclosures except for the following:

  • For treatment
  • For billing and collection of payment for your treatment
  • For Hospice healthcare operations
  • Occurring as a byproduct of permitted uses and disclosures
  • Made to or requested by you or that you authorized
  • Made to individuals involved in your care, or for disaster relief purposes
  • Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations
  • As part of a limited set of information which does not contain certain information that would identify you

The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. To request this list or accounting of disclosures, you must submit your request on the appropriate form which can be obtained by contacting the Hospice Privacy Officer at the address given below.

Right to Receive a Paper Copy of this Notice: You or your representative have the right to an additional copy of this notice at any time, even if you have received this notice previously. To obtain an additional copy, please contact Hospice’s Privacy Officer. The patient or patient’s representative may also obtain a copy of the current version of Hospice’s Notice of Privacy Practices at our website:


Hospice is required by law to maintain the privacy of your health information and to provide you or your representative a notice of its duties and privacy practices. Hospice is required to abide by the terms of this notice and may be amended from time to time. Hospice reserves the right to change the terms of its notice and to make the new notice provisions effective for all health information it maintains. If Hospice changes its notice, Hospice will provide a copy of the revised notice to you or your appointed representative. You or your personal representative has the right to express complaints to Hospice and to the Secretary of the DHHS if you or your representative believes that your privacy rights have been violated. Any complaints to Hospice should be made in writing to the Hospice Privacy Officer. Hospice encourages you to express any concerns you have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.


Hospice has designated the Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards.


This notice is effective September 23, 2013


Hospice of Amador & Calaveras

1500 S. Hwy 49 #105

Jackson, CA 95642

(209) 223-5500