HIPAA Notice of Privacy Practices
Hospice of the Chesapeake
90 Ritchie Highway, Pasadena, MD, 21122
Toll Free 877-462-1101, or 410-987-2003

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry
out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health information. “Protected health information” is
information about you, including demographic information, that may identify you and that relates to your past, present or
future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your
health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment:
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health care with a third party. For example, your
protected health information may be provided to a physician to whom you have been referred to ensure that the physician
has the necessary information to diagnose or treat you.

Payment:
Your protected health information will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the
health plan to obtain approval for the hospital admission.

Healthcare Operations:
We may use or disclose, as-needed, your protected health information in order to support the business activities of your
physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of
medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may
disclose your protected health information to medical school students that see patients at our office. In addition, we may
use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We
may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to remind you of your appointment, and inform you about
treatment alternatives or other health-related benefits and services that may be of interest to you.
We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as required by law, public health issues as required by law, communicable diseases, health oversight,
abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral
directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation,
inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request.
Under the law, we must also disclose your protected health information when required by the Secretary of the Department
of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or
opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the
extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in
the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Under federal law,
however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable
anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted
by law, information that is related to medical research in which you have agreed to participate, information whose
disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of
confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to
use or disclose any part of your protected health information and by law we must comply when the protected health
information pertains solely to a health care item or service for which the health care provider involved has been paid out of
pocket in full. You may also request that any part of your protected health information not be disclosed to family members
or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.
Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may
not request that we restrict the disclosure of your PHI for treatment purposes.

You have the right to request to receive confidential communications – You have the right to request confidential
communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this
notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You have the right to request an amendment to your protected health information – If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of
all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare
operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.
You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice
electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the
following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been
violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not
retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and
privacy practices with respect to protected health information. We are also required to abide by the terms of the
notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA
Compliance Officer in person or by phone at our main phone number.

Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are
only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy
Practices.