PRIVACY PRACTICE: Notice of Privacy Practices
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. USE AND DISCLOSURE OF HEALTH INFORMATION:

Star of Texas Hospice may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Star of Texas Hospice has established policies to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES

FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED: To Provide Treatment:

Star of Texas Hospice may use your health information to coordinate care within Star of Texas Hospice and with others involved in your care, such as your attending physician, members of Star of Texas Hospice interdisciplinary team and other health care professionals who have agreed to assist Star of Texas Hospice in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. Star of Texas Hospice also may disclose your health care information to individuals outside of Star of Texas Hospice involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment: Star of Texas Hospice may include your health information in invoices to collect payment from third parties for the care you receive from Star of Texas Hospice. For example, Star of Texas Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Star of Texas Hospice. Star of Texas Hospice also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for Star of Texas Hospice care and the services that will be provided to you.

To Conduct Health Care Operations: Star of Texas Hospice may use and disclose health information for its own operations in order to facilitate the function of Star of Texas Hospice and as necessary to provide quality care to all of Star of Texas Hospice patients. Health care operations includes such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Training of non-health care professionals.
• Accreditation, certification, licensing or credentialing activities.
• Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
• Business planning and development including cost management and planning-related analyses and formulary development.
• Business management and general administrative activities of the Star of Texas Hospice

For example, Star of Texas Hospice may use your health information to evaluate its staff performance, combine your health information with other Star of Texas Hospice patients in evaluating how to more effectively serve all Star of Texas Hospice patients, disclose your health information to Star of Texas Hospice staff and contracted personnel for training purposes or use your health information to contact you as a reminder regarding a visit to you.

For Informational Purposes in Star of Texas Hospice Inpatient Facility: Star of Texas Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in Star of Texas Hospice facility in an Star of Texas Hospice directory while you are in the Star of Texas Hospice inpatient facility. Star of Texas Hospice may disclose this information to people who ask for you by name. Please inform us if you do not want your information to be included in the directory. When Legally Required : Star of Texas Hospice will disclose your health information when it is required to do so by any Federal, State or local law.

For Appointment Reminders: Star of Texas Hospice may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit. For Treatment Alternatives: Star of Texas Hospice may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

For Marketing, Bereavement and Support Groups: This will serve as written affirmation that patient and or representative listed on the signature page of this agreement agree to allow hospice to use patient, family or representative’s information. The patient and, or representative as listed on the signature page can opt out by notifying the Privacy Officer. You may contact this person at: Star of Texas Hospice 510 Bering Drive Suite #300 Houston TX 77057. Email Address: admin@staroftexashospice.com

To Report Abuse, Neglect Or Domestic Violence: Star of Texas Hospice is allowed to notify government authorities if Star of Texas Hospice believes a patient is the victim of abuse, neglect or domestic violence. Star of Texas Hospice will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure. In regards to self-reported incidents of abuse, neglect and exploitation, pursuant to Texas Administrative Code Title 40, Rule 97.249, the following numbers can be used to report incidents: The Department of Family and Protective Services (DFPS) at 1.800.252.5400, through the DFPS secure website at www.txabusehotline.org or the Texas Department of Aging and Disability Services at 1.800.458.9858. In the Event of A Serious Threat To Health Or Safety: Star of Texas Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if Star of Texas 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. When There Are Risks to Public Health: Star of Texas 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.
• 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.
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting
• or spreading a disease.
• Notify an employer about an individual who is a member of the workforce as legally required.

To Conduct Health Oversight Activities: Star of Texas 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. Star of Texas 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.

In Connection With Judicial And Administrative Proceedings: The Star of Texas 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 Star of Texas Hospice makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes: As permitted or required by State law, the Star of Texas Hospice may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

• As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
• 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.
• To a law enforcement official if the Star of Texas Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct at the Star of Texas Hospice.
• In an emergency in order to report a crime or death.

To Funeral Directors: Star of Texas 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, Star of Texas Hospice may disclose your health information prior to and in reasonable anticipation of your death.

To Coroners And Medical Examiners: Star of Texas 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.

For Research Purposes: Star of Texas Hospice may, under very select circumstances, use your health information for research. Before Star of Texas Hospice discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.

For Specified Government Functions: In certain circumstances, the Federal regulations authorize Star of Texas 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. Further you authorize information related to services provided under this Agreement available to the Secretary of Health and Human Services as may be required to document the parties’ compliance with HIPAA Privacy Standards.

For Worker’s Compensation: Star of Texas Hospice may release your health information for worker’s compensation or similar programs.

For Organ, Eye Or Tissue Donation: Star of Texas 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.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION: Other than is stated above, Star of Texas Hospice will not disclose your health information other than with your written authorization. If you or your representative authorizes Star of Texas Hospice to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION: You have the following rights regarding your health information that Star of Texas Hospice maintains:
Right to receive confidential communications: You have the right to request that Star of Texas Hospice communicate with you in a certain way. For example, you may ask that Star of Texas 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 Star of Texas Hospice Privacy Official. Star of Texas Hospice will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications. Under the Health Information Technology for ECommerce and Clinical Health Act of 2009, patient/representative listed on the signature page of this agreement, may have the right to request electronic copies of information held electronically by the hospice and that patients or representatives listed on the signature page of this agreement, may have the right to restrict disclosure of encounter information to insure if it is paid fully out of pocket by the individual. The patient or representatives listed on the signature page of this agreement, authorizes hospice to exchange information electronically, in the context of this agreement, at the hospices’ direction and determination of need.

Right to inspect and copy your health information: I authorize Star of Texas Hospice to compile and maintain a health care file. I also authorize Star of Texas Hospice to make voice and video recordings as they deem necessary. 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 Official. If you request a copy of your health information, Star of Texas Hospice may charge a reasonable fee for copying and assembling costs associated with your request.

Right to amend health care information: You or your representative have the right to request that Star of Texas Hospice amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by Star of Texas Hospice. A request for an amendment of records must be made in writing to Star of Texas Hospice Privacy Official. Star of Texas Hospice may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Star of Texas Hospice, if the records you are requesting are not part of Star of Texas Hospice records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Star of Texas Hospice the records containing your health information are accurate and complete.

Right to an accounting: You or your representative have the right to request an accounting of disclosures of your health information made by Star of Texas Hospice for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to Star of Texas Hospice Privacy Official. The request should specify the time period for the accounting starting on or after August 1, 2011. Accounting requests may not be made for periods of time in excess of six (6) years. Star of Texas Hospice would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to request restrictions: You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Star of Texas Hospice disclosure of your health information to someone who is involved in your care or the payment of your care. However, Star of Texas Hospice is not required to agree to your request. If you wish to make a request for restrictions, please contact Star of Texas Hospice Privacy Official for your area. All contact information is listed at the bottom of this page.

Right to a paper copy of this notice: You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact the Star of Texas Hospice Privacy Official. The patient or a patient’s representative may also obtain a copy of the current version of Star of Texas Hospice of Privacy Practices at its website, www.staroftexashospice.com

DUTIES OF STAR OF TEXAS HOSPICE: Star of Texas Hospice is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. Star of Texas Hospice is required to abide by the terms of this Notice as may be amended from time to time. Star of Texas 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 Star of Texas Hospice changes its Notice, Star of Texas Hospice will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative have the right to express complaints to Star of Texas Hospice and to the Secretary of the Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to Star of Texas Hospice should be made in writing to the Star of Texas Hospice Privacy Official. Star of Texas 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.

EFFECTIVE DATE: This Notice is effective as of September 20, 2013.

CONTACT PERSON: Star of Texas Hospice has designated the Alternate Administrator to serve as the Privacy Officer for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at: Star of Texas Hospice 5433 Westheimer Suite 920 Houston Texas 77056 email: admin@staroftexashospice.com