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.

IntrepidUSA Home Health Services and Intrepid USA Hospice (the Agency) may use your health information that is defined as protected health information in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Agency has established policies 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 typically used and disclosed

The Agency may use your health information to coordinate care within the Agency and with others involved in your care, such as your attending physician, Intrepid USA nurses (Home Health Services and Hospice) and other health care professionals who have agreed to assist the Agency in coordination of care. The Agency also may disclose your health care information to individuals outside of the Agency involved in your care including your primary family caregiver, pharmacists, suppliers of medical equipment or other health care professionals.

The Agency may include your health information in invoices to collect payment from third parties for the care you receive from the Agency. For example, the Agency may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Agency. The Agency also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for home care and the services that will be provided to you.

The Agency may use and disclose health information for its own operations in order to facilitate the functions of the Agency and as necessary to provide quality care to all of the Agency’s patients. The Agency may use your health information to coordinate care within the Agency and with others involved in your care, such as Intrepid USA nurses (Home Health Services and Hospice). Health care operations include such activities as quality improvement, cost containment, case management activities, performance evaluation, training of employees and students, accreditation, auditing and business planning.

The Agency may use and disclose your health information when we contact you as a reminder that you have an appointment for a home visit.

The Agency may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that might be of interest to you. This may include a change in level of care or recommendation to utilize Intrepid USA Hospice services.

The Agency will disclose your health information when it is required to do so by any Federal, State or local law.

The Agency may disclose your health information for public activities and purpose in order to prevent or control disease, report disease or death, or report adverse events with products or medication, for example.

The Agency is allowed to notify government authorities if the Agency believes a patient is the victim of abuse, neglect or domestic violence. The Agency will make this disclosure to the extent the disclosure is: a) required by law; b) agreed by you or; c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims.

The Agency 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 Agency, 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.

The Agency 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 the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

As permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes.

The Agency 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.

The Agency 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.

When directed, the Agency 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 facilitation the donation and transplantation.

The Agency may, under very select circumstances, use your health information for research. Before the Agency discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.

The Agency may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Agency, 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.

In certain circumstances, the Federal regulations authorize the Agency 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.

The Agency may release your health information for worker’s compensation or similar programs.

Authorization to use or disclose health information

Other than is stated above, the Agency will not disclose your health information other than with your written authorization. More specifically, most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information require authorization; and other uses not described above will be made only with your written authorization. If you or your representative authorizes the Agency 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

You may request restrictions on certain use and disclosures of your health information. You have the right to request a limit on the Agency’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Agency is not required to agree to your request except for requests not to share treatment information with a health plan if you have paid out of pocket and in full. If you wish to make a request for restrictions, please contact the administrator/manager of the Agency. You may send your written request through the professional that admitted you to the Agency or you may mail the request.

You have the right to request that the Agency communicate with you in a certain way. For example, you may ask that the Agency 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, in writing, the administrator/manager of the Agency. The Agency will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications. You may send your written request through the professional that admitted you to the Agency or you may mail the request.

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 administrator/manager of the agency. This must be a written request. If you request a copy for your health information, the Agency may charge a reasonable fee for copying and assembling costs associated with your request. Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information.

You or your representative has the right to request that the Agency 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 the Agency. A request for an amendment of records must be made in writing to the administrator or branch manager. The Agency may deny the request if it is not in writing or does not include reason for the amendment. The request also may be denied if your health information records were not created by the Agency, if the records you are requesting are not part of the Agency’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 the agency, the records containing your health information are accurate and complete.

You or your representative have the right to request an accounting of disclosures of your health information made by the Agency for certain non-routine reasons related to public purposes or authorized by law. The request for an accounting must be made in writing to the administrator or branch manager. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years and prior to April 14, 2003. Accounting requests may be subject to a reasonable cost-based fee.

Right to a paper copy of this notice. You or your representative has 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 request a copy form your care provider. The patient or a patient’s representative may also obtain a copy of the current version of the Agency’s Notice of Privacy Practices at its website, www.intrepidusa.com.

Right to notice of a breach. You or your representative has a right to be notified following a breach of unsecured protected health information. Within 60 days after Agency discovers a breach of your protected health information you will be notified by mail.

Duties of the Agency

The Agency 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. The Agency is required to abide by the terms of this Notice as it may be amended from time to time. The Agency 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 the Agency changes it Notice, the Agency will provide a copy of the revised Notice to you or your appointed representative.

Right to file a complaint

You or your personal representative have the right to express complaints to the Agency and to the Secretary of the Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to the Agency should be made in writing to the Privacy Officer at the address below or e-mailed to intrepid@intrepidusa.com. The Agency 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

The Agency has designated the Privacy Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. Complaints against the provider can be mailed to:

Privacy Officer
Intrepid U.S.A. Corporate Service Center
4055 Valley View Lane, Suite 750
Dallas, TX 75244
1-866-412-0973

If you have any questions regarding this notice, please call the Intrepid Privacy Officer at 1-866-412-0973

This Notice is effective April 14, 2003