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| Privacy Statement |
- • 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.
and 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
Copyright © 2006 Willow Tree Hospice. All rights reserved.