NOTICE OF PRIVACY PRACTICES - Atlanta

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800) 700-0859.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

3720 DaVinci Court, Suite 400

Norcross, GA 30092

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

3720 DaVinci Court, Suite 400

Norcross, GA 30092

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Birmingham

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800)985-3305.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

33 Inverness Center Parkway, Suite 350

Hoover, AL 35242

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

33 Inverness Center Parkway, Suite 350

Hoover, AL 35242

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

Alcohol & Drug Abuse Information

We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

Summary of State Laws

General Health Information 

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.CA, FL, IN, MN, MT, NE, NJ, PR, RI, TN, TX, WA

You may be able to restrict certain electronic disclosures of health information.NV

We are not allowed to use health information for certain purposes.CA, NH, TN

We will not use and/or disclosure information regarding certain public assistance programs except for certain purposesAL, CA, MO, MT, NV, NJ, SD

We are allowed to disclose certain immunization records only (1) under certain limited circumstances, and/or disclose only (2) to specific recipientsHI

We must restrict access to records of minors subject to a court protective orderIL

Prescriptions

We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and /or (2) to specific recipients.AL, CT, FL, ID, IN, KY, MI, NE, NV, NH, NY, OH, RI, SC, TN, UT, WY

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2) to specific recipients.AZ, IA, IN, KS, MI, MT, NE, NV, NM, OK

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, FL, HI, IL, IN, IA, KS, MA, MI, MT, NV, NJ, NM, OK, WA, WV, WY

We are not allowed to identify certain abortion patients in legal proceedingsOK

Alcohol and Drug Abuse

We are not allowed to disclose alcohol and drug abuse information without your written consent.NE, WV

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.CA, CT, FL, GA, HI, IL, IN, IA, LA, MD, MA, MI, MS, NV, NH, NC, PA, VA, WA, WI, WY

Genetic Information

We are not allowed to disclose genetic information without your written consent.KS, NH, NY, TX

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, FL, IL, LA, MA, MO, NV, NJ, NM, OR, RI, VT, WA, WY

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.AK, NM, WY

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, CO, CT, DE, FL,GA, HI, IA, IL, IN, KS, KY, ME, MD, MA, MI, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, PA, PR, RI, TX, WA, WV, WY

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.CT, FL

Mental Health

We are not allowed to disclose mental health information without your written consent.NE, PR, UT

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, CA, CT, DC, HI, IA, IL, IN, ME, MD, MI, MS, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, WA, WI

Certain restrictions apply to oral disclosures of mental health information.CT

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.IL

NOTICE OF PRIVACY PRACTICES - Boston

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800)956-1276.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

950 Winter Street, Suite 4830

Waltham, MA 02451 

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

950 Winter Street, Suite 4830

Waltham, MA 02451 

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Cincinnati

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (888)866-8286.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

9050 Centre Pointe Drive, Suite 400

West Chester, OH 45069

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

9050 Centre Pointe Drive, Suite 400

West Chester, OH 45069

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

Alcohol & Drug Abuse Information

We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

Summary of State Laws

General Health Information 

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.CA, FL, IN, MN, MT, NE, NJ, PR, RI, TN, TX, WA

You may be able to restrict certain electronic disclosures of health information.NV

We are not allowed to use health information for certain purposes.CA, NH, TN

We will not use and/or disclosure information regarding certain public assistance programs except for certain purposesAL, CA, MO, MT, NV, NJ, SD

We are allowed to disclose certain immunization records only (1) under certain limited circumstances, and/or disclose only (2) to specific recipientsHI

We must restrict access to records of minors subject to a court protective orderIL

Prescriptions

We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and /or (2) to specific recipients.AL, CT, FL, ID, IN, KY, MI, NE, NV, NH, NY, OH, RI, SC, TN, UT, WY

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2) to specific recipients.AZ, IA, IN, KS, MI, MT, NE, NV, NM, OK

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, FL, HI, IL, IN, IA, KS, MA, MI, MT, NV, NJ, NM, OK, WA, WV, WY

We are not allowed to identify certain abortion patients in legal proceedingsOK

Alcohol and Drug Abuse

We are not allowed to disclose alcohol and drug abuse information without your written consent.NE, WV

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.CA, CT, FL, GA, HI, IL, IN, IA, LA, MD, MA, MI, MS, NV, NH, NC, PA, VA, WA, WI, WY

Genetic Information

We are not allowed to disclose genetic information without your written consent.KS, NH, NY, TX

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, FL, IL, LA, MA, MO, NV, NJ, NM, OR, RI, VT, WA, WY

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.AK, NM, WY

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, CO, CT, DE, FL,GA, HI, IA, IL, IN, KS, KY, ME, MD, MA, MI, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, PA, PR, RI, TX, WA, WV, WY

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.CT, FL

Mental Health

We are not allowed to disclose mental health information without your written consent.NE, PR, UT

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, CA, CT, DC, HI, IA, IL, IN, ME, MD, MI, MS, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, WA, WI

Certain restrictions apply to oral disclosures of mental health information.CT

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.IL

NOTICE OF PRIVACY PRACTICES – Colorado Springs

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (866)840-9253.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

5450 Tech Center Drive, Bldg 1, Suite 120

Colorado Springs, CO 80919

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

5450 Tech Center Drive, Bldg 1, Suite 120

Colorado Springs, CO 80919

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Columbia

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;

2. Mental health;

3. Genetic tests;

4. Alcohol and drug abuse;

5. Sexually transmitted diseases and reproductive health information; and

6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• ?You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• ?You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• ?You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• ?You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• ?You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• ?You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• ?You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• •Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800)543-0696.  
• •Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

6095 Marshalee Drive

Elkridge, MD 21075

• •Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

6095 Marshalee Drive

Elkridge, MD 21075

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. 1.show the categories of health information that are subject to these more restrictive laws; and 
2. 2.give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Dayton

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (877)785-2525.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

130 W Second Street, Suite 400

Dayton, OH 45402

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

130 W Second Street, Suite 400

Dayton, OH 45402

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Denver

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800)458-5346.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

6455 S Yosemite Street, 6^th Floor

Englewood, CO 80111

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

6455 S Yosemite Street, 6^th Floor

Englewood, CO 80111

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Macon

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (866)846-1310.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

4875 Riverside Drive, Suite 104

Macon, GA 31210

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

4875 Riverside Drive, Suite 104

Macon, GA 31210

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Philadelphia

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. 

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment.
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law.
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances:

• As Required by Law. We may disclose information when required to do so by law. 
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime. 
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. 
• For Data Breach Notification Purposes. We may use your contact information to provide legally-requirednotices of unauthorized acquisition, access, or disclosure of your health information.   
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;

2. Mental health;

3. Genetic tests;

4. Alcohol and drug abuse;

5. Sexually transmitted diseases and reproductive health information; and

6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information.

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.”

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full. 
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below.
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information.
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting. 
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (866) 585-2066. 
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

            Evercare Hospice

            Attn:  Executive Director

            700 American Avenue, Suite 206

            King of Prussia, PA 19406

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

            700 American Avenue, Suite 206

            King of Prussia, PA 19406

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law. 

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Phoenix

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (866)658-4658.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

3141 North Third Avenue

Phoenix, AZ 85013

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

3141 North Third Avenue

Phoenix, AZ 85013

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

 UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

Alcohol & Drug Abuse Information

We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

Summary of State Laws

General Health Information 

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.CA, FL, IN, MN, MT, NE, NJ, PR, RI, TN, TX, WA

You may be able to restrict certain electronic disclosures of health information.NV

We are not allowed to use health information for certain purposes.CA, NH, TN

We will not use and/or disclosure information regarding certain public assistance programs except for certain purposesAL, CA, MO, MT, NV, NJ, SD

We are allowed to disclose certain immunization records only (1) under certain limited circumstances, and/or disclose only (2) to specific recipientsHI

We must restrict access to records of minors subject to a court protective orderIL

Prescriptions

We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and /or (2) to specific recipients.AL, CT, FL, ID, IN, KY, MI, NE, NV, NH, NY, OH, RI, SC, TN, UT, WY

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2) to specific recipients.AZ, IA, IN, KS, MI, MT, NE, NV, NM, OK

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, FL, HI, IL, IN, IA, KS, MA, MI, MT, NV, NJ, NM, OK, WA, WV, WY

We are not allowed to identify certain abortion patients in legal proceedingsOK

Alcohol and Drug Abuse

We are not allowed to disclose alcohol and drug abuse information without your written consent.NE, WV

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.CA, CT, FL, GA, HI, IL, IN, IA, LA, MD, MA, MI, MS, NV, NH, NC, PA, VA, WA, WI, WY

Genetic Information

We are not allowed to disclose genetic information without your written consent.KS, NH, NY, TX

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, FL, IL, LA, MA, MO, NV, NJ, NM, OR, RI, VT, WA, WY

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.AK, NM, WY

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, CO, CT, DE, FL,GA, HI, IA, IL, IN, KS, KY, ME, MD, MA, MI, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, PA, PR, RI, TX, WA, WV, WY

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.CT, FL

Mental Health

We are not allowed to disclose mental health information without your written consent.NE, PR, UT

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, CA, CT, DC, HI, IA, IL, IN, ME, MD, MI, MS, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, WA, WI

Certain restrictions apply to oral disclosures of mental health information.CT

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.IL

NOTICE OF PRIVACY PRACTICES - Reston

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (888)245-1384.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

12018 Sunrise Valley Drive, Suite 400

Reston, VA 20191

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

12018 Sunrise Valley Drive, Suite 400

Reston, VA 20191

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES – San Antonio

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. 

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected.

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment.
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law.
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances:

• As Required by Law. We may disclose information when required to do so by law. 
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime. 
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. 
• For Data Breach Notification Purposes. We may use your contact information to provide legally-requirednotices of unauthorized acquisition, access, or disclosure of your health information.   
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;

2. Mental health;

3. Genetic tests;

4. Alcohol and drug abuse;

5. Sexually transmitted diseases and reproductive health information; and

6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information.

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.”

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full. 
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below.
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information.
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting. 
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (866) 937-4186. 
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

            Evercare Hospice

            Attn:  Executive Director

            5835 Callaghan Road, Suite 400

            San Antonio, TX 78228

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

            5835 Callaghan Road, Suite 400

            San Antonio, TX 78228

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law. 

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES – Santa Ana

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (877)609-0747.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

3110 Lake Center Drive

Santa Ana, CA 92704

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

3110 Lake Center Drive

Santa Ana, CA 92704

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

Alcohol & Drug Abuse Information

We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

Summary of State Laws

General Health Information 

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.CA, FL, IN, MN, MT, NE, NJ, PR, RI, TN, TX, WA

You may be able to restrict certain electronic disclosures of health information.NV

We are not allowed to use health information for certain purposes.CA, NH, TN

We will not use and/or disclosure information regarding certain public assistance programs except for certain purposesAL, CA, MO, MT, NV, NJ, SD

We are allowed to disclose certain immunization records only (1) under certain limited circumstances, and/or disclose only (2) to specific recipientsHI

We must restrict access to records of minors subject to a court protective orderIL

Prescriptions

We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and /or (2) to specific recipients.AL, CT, FL, ID, IN, KY, MI, NE, NV, NH, NY, OH, RI, SC, TN, UT, WY

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2) to specific recipients.AZ, IA, IN, KS, MI, MT, NE, NV, NM, OK

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, FL, HI, IL, IN, IA, KS, MA, MI, MT, NV, NJ, NM, OK, WA, WV, WY

We are not allowed to identify certain abortion patients in legal proceedingsOK

Alcohol and Drug Abuse

We are not allowed to disclose alcohol and drug abuse information without your written consent.NE, WV

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.CA, CT, FL, GA, HI, IL, IN, IA, LA, MD, MA, MI, MS, NV, NH, NC, PA, VA, WA, WI, WY

Genetic Information

We are not allowed to disclose genetic information without your written consent.KS, NH, NY, TX

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, FL, IL, LA, MA, MO, NV, NJ, NM, OR, RI, VT, WA, WY

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.AK, NM, WY

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, CO, CT, DE, FL,GA, HI, IA, IL, IN, KS, KY, ME, MD, MA, MI, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, PA, PR, RI, TX, WA, WV, WY

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.CT, FL

Mental Health

We are not allowed to disclose mental health information without your written consent.NE, PR, UT

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, CA, CT, DC, HI, IA, IL, IN, ME, MD, MI, MS, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, WA, WI

Certain restrictions apply to oral disclosures of mental health information.CT

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.IL

NOTICE OF PRIVACY PRACTICES - Schaumburg

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (877)370-1137.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

1900 E Golf Road, 2nd Floor

Schaumburg, IL 60173

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

1900 E Golf Road, 2nd Floor

Schaumburg, IL 60173

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1.show the categories of health information that are subject to these more restrictive laws; and 

2.give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

Alcohol & Drug Abuse Information

We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients.

Summary of State Laws

General Health Information 

We are allowed to disclose general health information only (1) under certain limited circumstances, and /or (2) to specific recipients.CA, FL, IN, MN, MT, NE, NJ, PR, RI, TN, TX, WA

You may be able to restrict certain electronic disclosures of health information.NV

We are not allowed to use health information for certain purposes.CA, NH, TN

We will not use and/or disclosure information regarding certain public assistance programs except for certain purposesAL, CA, MO, MT, NV, NJ, SD

We are allowed to disclose certain immunization records only (1) under certain limited circumstances, and/or disclose only (2) to specific recipientsHI

We must restrict access to records of minors subject to a court protective orderIL

Prescriptions

We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and /or (2) to specific recipients.AL, CT, FL, ID, IN, KY, MI, NE, NV, NH, NY, OH, RI, SC, TN, UT, WY

Communicable Diseases

We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and /or (2) to specific recipients.AZ, IA, IN, KS, MI, MT, NE, NV, NM, OK

Sexually Transmitted Diseases and Reproductive Health

We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, FL, HI, IL, IN, IA, KS, MA, MI, MT, NV, NJ, NM, OK, WA, WV, WY

We are not allowed to identify certain abortion patients in legal proceedingsOK

Alcohol and Drug Abuse

We are not allowed to disclose alcohol and drug abuse information without your written consent.NE, WV

We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.CA, CT, FL, GA, HI, IL, IN, IA, LA, MD, MA, MI, MS, NV, NH, NC, PA, VA, WA, WI, WY

Genetic Information

We are not allowed to disclose genetic information without your written consent.KS, NH, NY, TX

We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, FL, IL, LA, MA, MO, NV, NJ, NM, OR, RI, VT, WA, WY

Restrictions apply to (1) the use, and/or (2) the retention of genetic information.AK, NM, WY

HIV / AIDS

We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients.AZ, CA, CO, CT, DE, FL,GA, HI, IA, IL, IN, KS, KY, ME, MD, MA, MI, MO, MT, NE, NV, NH, NM, NY, NC, OH, OK, OR, PA, PR, RI, TX, WA, WV, WY

Certain restrictions apply to oral disclosures of HIV/AIDS-related information.CT, FL

Mental Health

We are not allowed to disclose mental health information without your written consent.NE, PR, UT

We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients.AK, AZ, CA, CT, DC, HI, IA, IL, IN, ME, MD, MI, MS, NV, NH, NJ, NM, NY, NC, OK, PA, RI, SC, SD, TN, TX, UT, WA, WI

Certain restrictions apply to oral disclosures of mental health information.CT

Child or Adult Abuse

We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients.IL

NOTICE OF PRIVACY PRACTICES – St. Louis

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (800)213-4188.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

13655 Riverport Drive

Maryland Heights, MO 63043

• •Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

13655 Riverport Drive

Maryland Heights, MO 63043

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws

NOTICE OF PRIVACY PRACTICES - Tucson

NOTICE FOR MEDICAL INFORMATION: Pages 1 - 5.

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.

Effective April 1, 2011.

Evercare Hospice, Inc. is required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice.  We are required by law to abide by the terms of this notice.

The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care.

We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide a revised notice by direct mail to you reflecting that change within 60 days of the change and we will otherwise post the revised notice on our website www.evercarehospice.com.  We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future.  

How We Use or Disclose Information

We must use and disclose your health information to provide that information:

• ?To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and
• ?To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. 

We have the right to use and disclose health information for your treatment, to bill for your health care and to operate our business. For example, we may use or disclose your health information:

• For Payment. We may use or disclose health information to obtain payment for health care services.  We may ask for advance payment. 
• For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.  For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
• For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care. For example, we might analyze data to determine how we can improve our services.
• To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. 
• For Reminders. We may use or disclose health information to send you reminders about your care, such as appointment reminders with providers who provide medical care to you or reminders related to medicines prescribed for you.

We may use or disclose your health information for the following purposes under limited circumstances: 

• As Required by Law. We may disclose information when required to do so by law.  
• To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity.  If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests.
• For Public Health Activities such as reporting or preventing disease outbreaks.
• For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency.
• For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations.
• For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
• For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.  
• To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster or to the Food and Drug Administration (FDA) or persons under the jurisdiction of the FDA related to safety or quality issues, adverse events or to facilitate drug recalls.
• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others.
• For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.
• For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets privacy law requirements.
• To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
• To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.  
• For Data Breach Notification Purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information.    
• Additional Restrictions on Use and Disclosure.  Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information as well as state laws that often protect the following types of information:

1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.

If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.  Attached to this notice is a Summary of Federal and State Laws on Use and Disclosure of Certain Types of Medical Information. 

Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you.  For example, except for limited circumstances allowed by federal privacy law, we will not use or disclose psychotherapy notes about you, send marketing communications to you, or use your information without authorization.  Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already acted based on your authorization. To find out where how to revoke an authorization, use the contact information below under the section titled “Exercising Your Rights.” 

What Are Your Rights

The following are your rights with respect to your health information:

• You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction.
• You have the right to request that we not send health information to health plans in certain circumstances if the health information concerns a health care item or service for which you have paid us out of pocket in full.  
• You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address).  We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you.  We will accept verbal requests to receive confidential communications, but requests to modify or cancel a previous confidential communication request must be made in writing.  Mail your request to the address listed below. 
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as medical records. You also may in some cases receive a summary of this health information. You must make a written request to inspect and copy your health information.  Mail your request to the address listed below.  In certain limited circumstances, we may deny your request to inspect and copy your health information.  We may charge a reasonable fee for any copies.  If we deny your request, you have the right to have the denial reviewed.  If we maintain an electronic health record containing your health information, when and if we are required to comply with proposed changes to federal privacy laws, you will have the right to request that we send a copy of your health information in an electronic format to you or to a third party that you identify.  We may charge a reasonable fee for sending the electronic copy of your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete.  Your request must be in writing and provide the reasons for the requested amendment.  Mail your request to the address listed below.  If we deny your request, you may have a statement of your disagreement added to your health information. 
• You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) prior to April 14, 2003; (ii) for treatment, payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures for which federal law does not require us to provide an accounting.  
• You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also obtain a copy of this notice at our website, www.evercarehospice.com.

Exercising Your Rights

• Contacting your Provider.  If you have any questions about this notice or want to exercise any of your rights, please contact Evercare Hospice, Inc., Executive Director/Privacy Officer at (877)233-2902.  
• Submitting a Written Request.  Mail to us your written requests for modifying or cancelling a confidential communication, for copies of your records, or for amendments to your record, at the following address:

Evercare Hospice 

Attn:  Executive Director

6245 E Broadway, 5^th Floor

Tucson, AZ 85711

• Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the following address:

Evercare Hospice

Attn:  Executive Director

6245 E Broadway, 5^th Floor

Tucson, AZ 85711

You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint.

UNITEDHEALTH GROUP

PROVIDER PLAN NOTICE OF PRIVACY PRACTICES:

FEDERAL AND STATE AMENDMENTS

Revised: April 1, 2011

The first part of this Notice, which provides our privacy practices for Medical Information (pages 1 - 5), describes how we may use and disclose your health information under federal privacy rules.  There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules.  The purpose of the charts below is to:

1. show the categories of health information that are subject to these more restrictive laws; and 
2. give you a general summary of when we can or cannot use and disclose your health information without your consent.

If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.  

Summary of Federal Laws