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| Privacy Statement |
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.
Willow Tree Hospice may use your health information for purposes of providing you treatment, obtaining payment for
your care and conducting health care operations. Your health information may be used or disclosed only after Willow Tree
Hospice has obtained your written consent. Willow Tree Hospice has established a policy to guard against unnecessary
disclosure of your health information.
- • Willow Tree Hospice may use your health information to coordinate care within Willow Tree Hospice and with
others involved in your care, such as your attending physician, members of Willow Tree Hospice interdisciplinary
team and other health care professionals who have agreed to assist Willow Tree Hospice in coordinating care. Willow
Tree Hospice also may disclose your health care information to individuals outside of Willow Tree Hospice involved
in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical
equipment or other health care professionals that Willow Tree Hospice uses in order to coordinate your care.
• Willow Tree Hospice may include your health information in invoices to collect payment from third parties for the
care you may receive from Willow Tree Hospice. Willow Tree Hospice also may need to obtain prior approval from
your insurer and may need to explain to the insurer your need for hospice care and the services that will be provided
to you.
• Willow Tree Hospice may use and disclose health care information for its own operations in order to facilitate the
function of Willow Tree Hospice and as necessary to provide quality care to all Willow Tree Hospice patients.
Federal privacy rules allow Willow Tree Hospice to use or disclose your health information without your consent or
authorization for a number of reasons:
- • Willow Tree Hospice will disclose your health information when it is required to do so by any Federal, State or
local law.
• Willow Tree Hospice may disclose your health information for public activities and purposes in order to:
- - Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and
the conduct of public health surveillance, investigations and interventions.
- To report adverse events, product defects, to track products or enable product recalls, repairs and
replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and
Drug Administration.
- To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or
spreading a disease.
- To an employer about an individual who is a member of the workforce as legally required.
- • Willow Tree Hospice is allowed to notify government authorities if Willow Tree Hospice believes a patient is the
victim of abuse, neglect or domestic violence. Willow Tree Hospice will make this disclosure only when specifically
required or authorized by law or when the patient agrees to the disclosure.
- • Willow Tree Hospice may disclose your health information to a health oversight agency for activities including
audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Willow Tree
Hospice, however, may not disclose your health information if you are the subject of an investigation and your
health information is not directly related to your receipt of health care or public benefits.
- • Willow Tree Hospice may disclose your health information in the course of any judicial or administrative
proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in
response to a subpoena, discovery request or other lawful process, but only when Willow Tree Hospice makes
reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
- • Willow Tree Hospice may disclose your health information to a law enforcement official for law enforcement
purposes e.g.
- - For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
- - Under certain limited circumstances, when you are the victim of a crime.
- In an emergency in order to report a crime.
- • Willow Tree Hospice may disclose your health information to coroners and medical examiners for purposes of
determining your cause of death or for other duties, as authorized by law.
- • Willow Tree Hospice may disclose your health information to funeral directors consistent with applicable law and
if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their
duties, Willow Tree Hospice may disclose your health information prior to and in reasonable anticipation, of your
death.
- • Willow Tree Hospice may use or disclose your health information to organ procurement organizations or other
entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of
facilitating the donation and transplantation.
- • Willow Tree Hospice may, under very select circumstances, use your health information for research. Before
Willow Tree Hospice discloses any of your health information for such research purposes, the project will be subject
to an extensive approval process. Willow Tree Hospice will ask your permission if any researcher will be granted
access to your individually identifiable health information.
- • Willow Tree Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health
information if Willow Tree Hospice, in good faith, believes that such disclosure is necessary to prevent or lessen a
serious and imminent threat to your health or safety or to the health and safety of the public.
- • In certain circumstances, the Federal regulations authorize Willow Tree Hospice to use or disclose your health
information to facilitate specified government functions relating to military and veterans, national security and
intelligence activities, protective services for the President and others, medical suitability determinations and inmates
and law enforcement custody.
- • Willow Tree Hospice may release your health information for worker's compensation or similar programs.
Other than is stated above, Willow Tree Hospice will not disclose your health information other than with your written
authorization. If you or your representative authorizes Willow Tree Hospice to use or disclose your health information,
you may revoke that authorization in writing at any time.
You have the following rights regarding your health information that Willow Tree Hospice maintains:
- - You may request restrictions on certain uses and disclosures of your health information. You have the right
to request a limit on Willow Tree Hospice’s disclosure of your health information to someone who is involved
in your care or the payment of your care. However, Willow Tree Hospice is not required to agree to your
request. If you wish to make a request for restrictions, please contact the Privacy Officer for Willow Tree
Hospice at 866 WTREE77.
- - You have the right to request that Willow Tree Hospice only conduct communications pertaining to your
health information with you privately with no other family members present. If you wish to receive
confidential communications, please contact the Privacy Officer for Willow Tree Hospice at 866 WTREE77.
- - You have the right to inspect and copy your health information, including billing records. A request to
inspect and copy records containing your health information may be made to the Privacy Officer for Willow
Tree Hospice at 866 WTREE77.
assembling costs associated with your request.
- - If you or your representative believes that your health information records are incorrect or incomplete, you
may request that Willow Tree Hospice amend the records. That request may be made as long as the
information is maintained by Willow Tree Hospice. A request for an amendment of records must be made in
writing to the Privacy Officer for Willow Tree Hospice at 100 Sycamore Drive, West Grove Pa 19390.
Willow Tree Hospice may deny the request if it is not in writing or does not include a reason for the amendment.
You or your representative have the right to request an accounting of disclosures of your health information made by
Willow Tree Hospice for any reason other than for treatment, payment or health operations. The request for an accounting
must be made in writing to the Privacy Officer for Willow Tree Hospice at 100 Sycamore Drive, West Grove Pa 19390 Phone
# 610 869 2201 or 866 WTREE77 .
Willow Tree Hospice is required by law to maintain the privacy of your health information and to provide to you and your
representative this notice of privacy practices. Willow Tree Hospice is required to abide by terms of this notice as may be
amended from time to time. Willow Tree Hospice reserves the right to change the terms of its notice and to make the new
notice provisions effective for all health information that it maintains. If Willow Tree Hospice changes its notice, Willow
Tree Hospice will provide a copy of the revised notice to you or your appointed representative. You or your personal
representatives have the right to express complaints to Willow Tree Hospice and to the Secretary of Health and Human
Services if you or your representative believes that your privacy rights have been violated. Any complaints to Willow Tree
Hospice should be made in writing to the Privacy Officer for Willow Tree Hospice at 866 WTREE77. Willow Tree Hospice
encourages you to express any concerns you may have regarding the privacy of your information. You will not be
retaliated against in any way for filing a complaint.
The Willow Tree Hospice contact person for all issues regarding patient privacy and your rights under the Federal privacy
standards is Christine Coll RN Administrator.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
Privacy Officer: Christine Coll Administrator
Willow Tree Hospice
610 869 2201
866 WTREE77
