The Lower Cape Fear Hospice Health-Related Privacy Policy describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Lower Cape Fear Hospice is committed to protecting the information you share with us.

We follow all federal and state laws that require us to keep your information confidential. (The Health Information and Portability and Accountability Act (45 C.F.R. Part 160 and 164 HIPAA)). We will use and disclose your health information when we are required to do so by any federal, state or local law.

Where there is a conflict between state law and federal law, the agency will follow the stricter law.

This notice describes Lower Cape Fear Hospice’s practices at all locations. All employees, contractors, volunteers, and vendors are required to comply with the regulations.

Why we collect personal information

We may use or disclose your health information without authorization to provide, coordinate, or manage your healthcare and related services.

This includes sharing your health information with other healthcare providers for treatment alternatives, disclosing your health information to contracted personnel for training purposes, contacting you for appointments, or contacting you as part of community information and fundraising mailings (unless you tell us you do not want to be contacted).

Payment

Hospice may include your health information on Medicare or other insurance for the care you may receive from us.

For example, the agency may be required by your health insurer to provide information regarding your healthcare status so the insurance company will reimburse the agency.

Treatment

Hospice may use your health information within the agency and with others involved in your care, such as your attending physician, members of the interdisciplinary team and other healthcare professionals who have agreed to help hospice coordinate your care.

The agency may also disclose your healthcare information to individuals outside of hospice who are involved in your care, including designated family members, pharmacists, suppliers of medical equipment or other healthcare professionals.

Healthcare operations

Hospice may use and disclose healthcare information for its own operations as necessary to provide quality care to all of our patients. Healthcare operations include:

  • Accreditation, licensing, certification, or credentialing activities
  • Quality assessment and improvement activities
  • Activities designed to improve health or reduce healthcare costs
  • Professional review and performance evaluations
  • Auditing and compliance reviews, medical reviews, and legal services
  • Fundraising, unless you opt out
  • Training programs

We are also required to collect and send information to the North Carolina Department of Health and Human Services (DHHS) and Center for Medicaid and Medicare Services (CMS) to meet legal requirements.

We keep this information for a minimum seven years after your discharge from services unless you were a minor at the time of service.

We are required by law to maintain the privacy of your personal information and to provide you with a notice of our legal duties and privacy practices.

How we use and disclose your personal information

To conduct health oversight activities

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 agency 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 healthcare or public benefits.

Judicial and administrative proceedings

If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court order. We also may disclose PHI about you in response to a subpoena or other lawful process by someone else by furnishing your medical records under seal to the court.

For organ, eye, tissue, or body donation

If you are a patient, our agency may use or disclose your health information to organ procurement organizations for the purpose of facilitating the donation and transplantation. If you are an organ or tissue donor, we are required to provide medical information about you after your death to the agency that received the donation.

For research purposes

If you are a patient, our agency may, under select circumstances, use your health information for research. Before being used or disclosed, the project will be subject to an extensive approval process.

Fundraising activities

We may use or disclose health information about you, including disclosures to a foundation to contact you to raise money for our facility and its operations. We would only release contact information and the dates you received services. If you do not want to be contacted in this way, you must notify us in writing.

To coroners and medical examiners

Your health information may be disclosed to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To funeral directors

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.

To report abuse, neglect or domestic violence

We will notify authorities as required by law, if staff in good faith believe a patient is a victim of abuse, neglect, or domestic violence.

For risks to public health

We may disclose health information for public health activities to prevent or control disease, injury, or disability, vital events such as birth and death and for conducting public health surveillance, investigations, or interventions. We may report adverse events, product defects, track products or enable product recalls, repairs and replacements and to comply with requirements of the Food and Drug Administration.

For specified government functions

The agency will use or disclose your health information to facilitate government functions related to the military and veterans, national security, and intelligence activities.

For workers’ compensation

If you are a patient, our agency may release your PHI for workers’ compensation or similar programs under appropriate circumstances.

A serious threat to health and safety

The agency may use or disclose your health information to prevent or lessen a serious or imminent threat to you or the public. Any disclosure would be to an entity that could prevent the threat and be consistent with applicable law and ethical standards.

Any other uses or disclosures not already outlined in this notice are prohibited unless authorized by you, your personal representative, or is permitted by state or federal laws.

Your rights related to your Protected Health Information

The right to request limits on the uses and disclosures of your health information

You may request limits on certain uses and disclosures of your health information. You have the right to request a limit on hospice’s disclosure of your health information to someone who is involved in your care or the payment of your care. This includes disclosures to a health plan when you have paid your bill in full, out of pocket, at the time of service. We are not responsible for notifying providers downstream of any restrictions. Any such request must be submitted in writing to our Privacy Officer. We are not required to agree to your request.

The right to choose how we communicate with you

You have the right to ask we send information to you at a specific address (for example, at work rather than at home) or in a specific manner (for example, by email rather than mail). We must agree to your request as long as it is not disruptive to our operations to do so. You must submit a request in writing to our Privacy Officer.

The right to choose to see and copy your health information

You have the right to look at and copy your health information, including billing records. You must submit a request in writing to the Privacy Officer. In certain situations, we may deny your request, but if we do, we will tell you in writing of the reasons for the denial and explain your rights and how to have the denial reviewed. If you ask us for a copy of your health information, we may charge you a reasonable fee as allowed by law. Alternatively, we may supply you with a summary or explanation of your health information, as long as you agree to the cost in advance. If desired, you may request and receive a copy of your records in an electronic format.

The right to correct or update your health information

If you believe the health information we have is incorrect or incomplete, you may ask us to amend it. A request must be submitted in writing to the Privacy Officer and must include the reason why you think the amendment is appropriate. If we agree to make the amendment, we will ask you to tell us who else you would like us to notify of the amendment. We may deny your request to amend information that: was not created by us, is not part of the hospice’s records, if the 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. If we deny the amendment, we will tell you in writing how to submit a statement of disagreement, or to request to include your documents to amend in your health information.

The right to receive a list of the disclosures we have made

You have the right to receive a list of disclosures of your health information by the agency. The list will not include disclosures we have made for treatment or operations purposes, or for those that were made with your authorization. You may request a list of disclosures by submitting a request to the Privacy Officer. The request should specify the time period. The first list within a 12-month time period will be free. We will charge you our costs for any additional list within that 12-month period.

The right to notification of breach

If we determine there has been a breach of your protected health information, we will provide you or your representative with written notice directly, by first class mail, or by email if you agree to receive electronic notice.

The notification will be provided no later than 60 days following discovery of the breach. The notification will include a description of the breach, description of the type of information involved in the breach, steps you or your representative should take to protect you from harm; a brief description of what the agency is doing to investigate the breach and mitigate the harm, and prevent further breaches; and contact information for hospice.

The agency may notify you by phone as well as written notice if determined to require urgency because of possible misuse of protected health information.

The right to receive a paper copy of this notice

You may receive a paper privacy notice even if you have received the notice by email. You may obtain a paper copy by contacting the agency’s Privacy Officer.

How to file a complaint about our privacy practices

We have a legal duty to protect health information about you. If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the Privacy Officer at Lower Cape Fear Hospice.

We will not retaliate against you for filing a complaint.

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services Office of Civil Rights at the federal or regional level if you feel your privacy rights have been violated. You may fax, email, or mail your complaint.

To file online, go to http://www.hhs.gov/ocr. The complaint must be filed within 180 days of when you knew the act occurred. An extension may be given for “good cause.”

Lower Cape Fear Hospice’s Privacy Officer is available to assist you in filing a complaint with the U.S. Department of Health and Human Services Civil Rights office.

Regional Manager, Office for Civil Rights
U.S. Dept. of Health and Human Services
Atlanta Federal Center, STE-3B70
61 Forsyth St. SW
Washington, DC 20201
Phone: (404) 562-7886
Fax: (404) 562-7881
TDD: (404) 331-2867

Director, Office for Civil Rights
U.S. Dept. of Health and Human Services
200 Independence Blvd. SW
Room 509F, HHH Bldg.
Atlanta, GA, 30303-8909

Questions about this notice?
Lower Cape Fear Hospice
Privacy Officer
1414 Physicians Drive
Wilmington, NC 28401
Phone: 910-796-7900
Fax: 910-796-7910
Email: privacy@LCFH.org