Heart of Georgia Hospice
103 Westridge Drive
Warner Robins, GA 31088
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.
PURPOSE:This Notice of Privacy Practices
describes how we may use and disclose your Protected Health Information to carry out treatment, payment or
healthcare operations and for other purposes permitted or required by law. “Protected Health Information” is
information that may identify you and that relates to your past, present or future physical or mental health,
and may include your name, address, phone numbers and other identifying information.
We are required
to give you this Notice and to maintain the privacy of your Protected Health Information. We must abide by this
Notice, but we reserve the right to change the privacy practices described in it. A current version of this
Notice, with required revisions, if any, may be obtained from the Heart of Georgia Hospice web site,
http://www.heartofgahospice.org and will be posted in prominent areas of our facilities. You may also receive a
current copy by sending a written request to Heart of Georgia, 103 Westridge Dr. Warner Robins, GA
FOLLOW THIS NOTICE: This
Notice describes the practices of Heart of Georgia Hospice professionals, employees, volunteers and others who
work or provide healthcare services at any Heart of Georgia Hospice facility, including
Responsibilities - We are
required to protect the privacy of your Protected Health Information, abide by the terms of the Notice, and make
the Notice available to you. We are also required to notify you if a breach of your health information occurs
and will do so via registered mail.
DISCLOSURE OF HEALTH INFORMATION
Georgia Hospice, Inc. 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. The 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:
Treatment: Heart of
Georgia Hospice may use your health information to coordinate care within the Hospice and with others involved
in your care, such as your attending physician, members of the Hospice interdisciplinary team and other health
care professionals who have agreed to assist the a Hospice in coordinating care. For example, physicians
involved in your care will need information about your symptoms in order to prescribe appropriate medications.
The Hospice also may disclose your health care information to individuals outside of the Hospice involved in
your care including family members, 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.
Payment: Heart of
Georgia Hospice may include your health information in invoices to collect payment from third parties for the
care you may receive from the Hospice. For example, the Hospice may be required by your health insurer to
provide information regarding your health care status so that the insurer will reimburse you or the Hospice. The
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.
Health Care Operations:Heart of Georgia Hospice may use and disclose health care information for its own operations in order to
facilitate the function of the Hospice and as necessary to provide quality care to all of the Hospice’s
patients. Health care operations include such activities as:
assessment and improvement activities.
Activities designed to improve health or reduce health care costs.
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.
programs including those in which students, trainees or practitioners in health care learn under
Accreditation, certification, licensing or credentialing activities.
and auditing, including compliance reviews, medical reviews, legal services and compliance
planning and development including cost management and planning related analyses and formulary
management and general administrative activities of the Hospice.
Fundraising for the benefit of the Hospice and certain marketing activities.
For example, Heart of Georgia 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).
Fundraising Activities:Heart of Georgia Hospice may use information about you including your name, address, phone number and the
dates your received care at the Hospice in order to contact you or your family to raise money for the Hospice.
The Hospice many also release this information to a related Hospice foundation. If you do not want the hospice to contact you or your
family, please notify the Executive Director at Heart of Georgia Hospice by mail at: 103 Westridge Dr.
Warner Robins, GA 31088; or by email at firstname.lastname@example.org indicate that you do not wish to be
Federal privacy rules allow the Hospice to use or
disclose your health information without your consent or authorization for a number of
When legally required:
Heart of Georgia 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
Georgia Hospice may disclose your health information for public activities and purposes in order
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.
adverse events, product defects, to track products or enable product recalls, repairs and replacements
of the food and drug administration.
a person who has been exposed to a communicable disease or who may be at risk of contracting or
spreading a disease.
employer about an individual who is a member of the workforce as legally required.
To Report Abuse, Neglect or Domestic
Violence: Heart of
Georgia Hospice is allowed to notify government authorities if the Hospice believes a patient is the victim of
abuse, neglect or domestic violence. The Hospice will make this disclosure only when specifically required or
authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight
Activities: Heart of
Georgia 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. The
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
Georgia Hospice may disclose your health information in the course of any judicial or administrative proceedings
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 the Hospice makes reasonable
efforts to either notify you about the request or to obtain an order protecting your health
For Law Enforcement
Georgia Hospice may disclose your health information to a law enforcement official for law enforcement purposes
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.
purpose of identifying or locating a suspect, fugitive, material witness or missing
certain limited circumstances, when you are the victim of a crime.
To a law
enforcement official if the Hospice has a suspicion that your death was the result of criminal conduct
including criminal conduct at the Hospice.
emergency in order to report a crime.
To Coroners and Medical
Georgia Hospice may disclose your health information to coroners and medical examiners for purposes of
determining your cause of death or for the other duties, as authorized by law.
To Funeral Directors:
Heart of Georgia Hospice may disclose your
health information to funeral directors consistent with applicable law and is necessary, to carry out their
duties with respect to your funeral arrangements. If necessary to carry out their duties, the Hospice may
disclose your health information prior to and in reasonable anticipation, of your death.
For Organ, Eye, or Tissue
Georgia 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.
Georgia Hospice may, under very select circumstances, use your health information for research. Before the
Hospice discloses any of your health information for such research purposes, the project will be subject to an
extensive approval process. The Hospice 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: Heart of
Georgia Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health
information if the 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
For Specified Government
circumstances, the Federal regulations authorize Heart of Georgia 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.
Georgia Hospice may release your health information for worker’s compensation or similar
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than is
stated above, Heart of Georgia Hospice will not disclose your health information other than with your written
authorization. If you or your representative authorizes the Hospice to use or disclose your health information,
you may revoke that authorization in writing at any time.
Heart of Georgia
Hospice will not sell your information without your prior written authorization or as otherwise allowed by
WITH RESPECT TO YOUR HEALTH INFORMATION
You have the
following rights regarding your health information that the Hospice maintains:
Right to request
request restrictions on certain uses and disclosures of your health information. You have the right to request a
limit on the Hospice’s disclosure of your health information to someone who is involved in your care or the
payment of your care. Hospice
is not required to agree to your request, unless your request is for a restriction on a disclosure to a health
plan for purposes of payment or health care operations (and is not for purposes of treatment) and the medical
information you are requesting to be restricted from disclosure pertains solely to a health care item or service
for which you have paid out of pocket in full. If you wish to make a request for restrictions, please
contact the Executive Director
at Heart of Georgia Hospice by calling 478-953-5161.
Right to receive confidential communications:You have the right to request that the Hospice
communicate with you in a certain way. For example, you may ask that the 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 the Executive Director. The
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 health
information may be make to the Executive Director. If you request a copy of your health information, the
Hospice may charge a reasonable fee for copying and assembling costs associated with your
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 the Hospice amend the
records. That request may be made as long as the information is maintained by the Hospice. A request may
be made as long as the information is maintained by the Hospice. A request for an amendment of records
must be made in writing to the Executive Director. Heart of Georgia may deny the request if your health
information records were not created by us, if the records you are requesting are not part of our
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 Heart of Georgia 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 Heart of Georgia Hospice for any
reason other than for treatment, payment or health operations. The request for an accounting must be
made in writing to the Executive Director. The request should specify the time period for the requested
accounting. Accounting requests may not be made for periods of time in excess of six years. Heart of
Georgia 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 executive Director at 103
Westridge Drive Warner Robins, GA 31088. The office telephone number is 478-953-5161. The Hospice
patient or a representative may also obtain a copy of the current version of the Heart of Georgia
Hospice’s Notice of privacy practices at its website, www.heartofgahospice.com
HEART OF GEORGIA HOSPICE
Heart of Georgia
Hospice is required by law to maintain the privacy of your health information and to provide to you and your
representative this Notice of it duties and privacy practices. Heart of Georgia Hospice is required to abide by
terms of this Notice as may be amended from time to time. Heart of Georgia Hospice
right to change the terms of its Notice and to make the new Notice provisions effective for all health
information that it maintains. If Heart of Georgia Hospice changes its Notice, we 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 Heart of Georgia Hospice and to the Secretary of Health and Human Services if you or your
representative believes that your privacy rights have been violated. Any complaints to Heart of Georgia Hospice
should be made in writing to the attention of the Executive Director. Heart of Georgia 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.
Heart of Georgia
Hospice’s contact person for all issues regarding patient privacy and your rights under the Federal privacy
standards is the Executive Director at 103 Westridge Drive Warner Robins, GA 31088. The office telephone number
This notice is
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EXECUTIVE DIRECTOR AT 103
WESTRIDGE DRIVE WARNER ROBINS, GA 31088. THE OFFICE TELEPHONE NUMBER IS 478-953-5161.