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 DATE: July 17, 2020

Hospice of Southern Maine is required by law to maintain the privacy of your protected health information, to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information, and to notify affected patients following a breach of unsecured protected health information. Although we are required to abide by the terms of the Notice that is currently in effect, we reserve the right to change our privacy practices at any time and to make the new Notice provisions effective for all protected health information that we maintain. If our privacy practices change, we will make a revised Notice available to you upon request during our next visit or your next clinical encounter.

This Notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic and genetic information, that personally identifies you and relates to your past, present, or future physical or mental health or condition and related health care services. Protected health information also includes any health information and records provided to Hospice of Southern Maine (“HSM”) by other healthcare providers and facilities who have provided care to you or are involved in your care.

Authorized Uses and Disclosures of Your Protected Health Information

HSM may use and disclose your protected health information for purposes of treatment, payment, and healthcare operations, without your authorization. For example:

• Treatment: We may use or disclose your protected health information to other healthcare providers for treatment purposes and to arrange for the provision, coordination, and management of healthcare services for you. For example, HSM may disclose information about your symptoms to your physician in order to prescribe appropriate medications to you, or to a pharmacist to process your prescription, or to a medical equipment supplier for supplies and equipment necessary for your care.

• Payment: We may use or disclose protected health information about you to your health plan, insurance company or other third-party payors such as Medicare or MaineCare (Medicaid) to obtain payment or reimbursement for healthcare services provided to you, or to determine your eligibility for coverage and benefits, unless you request in writing that your protected health information not be disclosed to third-party payors and the protected health information relates to HSM services that you have paid HSM for in full. We may also disclose your protected health information to another health care practitioner or health care facility, or to a payor or person engaged in payment for health care (unless you notify us in writing not to make such disclosures to a third-party payor as indicated in the section above on “Payment” and in the section below on your right to request restrictions on disclosure) for purposes of care management or coordination of your care. However, we will make a reasonable effort to notify you or your authorized representative if we make such a disclosure for care management or coordination of care purposes.

• Healthcare Operations: We may use or disclose your protected health information for healthcare operations purposes, such as to evaluate the quality of the care and services provided to you or to conduct patient satisfaction surveys.

HSM may also use and disclose your protected health information without your authorization in the following additional circumstances:

• As Required or Authorized by Law: We may use and disclose your protected health information when required or authorized by applicable state and federal law.

• Business Associates: We may disclose your protected health information to business associate contractors that are performing services on behalf of HSM and have agreed in writing to maintain the privacy of your protected health information.

• Personal Representatives: We may disclose your protected health information to personal representatives, such as your legal guardian, healthcare power of attorney agent, or healthcare surrogate, who are authorized to make healthcare decisions on your behalf when you lack the capacity to make your own healthcare decisions.

• Staff Chaplains and Pastoral Care Staff, and Members of the Clergy: Our chaplains and pastoral care staff participating on our designated hospice interdisciplinary care team and involved in providing care to you may access and use your protected health information for the purpose of conducting and documenting comprehensive assessments of your spiritual needs required by law. They may also access your protected health information as necessary to offer and provide spiritual care to you in response to your spiritual needs, as well as to provide bereavement counseling services to your family. In addition, limited information we maintain about you in a facility directory—namely, your name, presence and room location in our facility, religious affiliation, and a brief general description of your health status and condition that does not communicate specific medical information about you—may be disclosed to outside members of the clergy who are not on our staff, unless you or your authorized representative notify us that you object to and wish to prohibit or restrict such disclosure.

• Gosnell Memorial Hospice House Facility Directory: Unless you notify us that you object to or wish to restrict such use or disclosure, our Gosnell Memorial Hospice House facility may (i) use your name, location (room number), condition described in general terms that do not communicate specific medical information about you, and religious affiliation, to maintain a directory of patients in the facility, and (ii) disclose your name, location and general condition to persons who ask for you by name.

• Persons Involved in Your Care and for Notification Purposes: We may disclose your protected health information to family members, relatives, or close personal friends involved in your care, involved in securing payment for your care, or for notification purposes, including after your death, unless you (or your authorized representative) notify us that you object to or wish to restrict such disclosures.

• Fundraising and Community Benefit Activities: We may use limited protected health information about you—namely, your name, address, contact information, age, gender, date of birth, dates you received services, department of service, treating physician, outcome information, and health insurance status-to contact you for fundraising and community benefit purposes (such as memorial and bereavement events) consistent with HSM’s nonprofit mission, unless you notify our Privacy Officer that you do not wish to receive such communications. We may also disclose such information to an institutionally related foundation to conduct fundraising activities for the benefit of HSM.

• Disaster Relief: We may use and disclose your protected health information to public or private entities authorized by law to assist in disaster relief efforts, provided you have been given the opportunity to agree or to object to such uses and disclosures.

• Public Health Activities: We may use and disclose your protected health information to public health authorities for public health activities, such as to comply with mandatory communicable disease and vital statistics reporting laws.

• Abuse, Neglect, and Exploitation Reporting: We may disclose your protected health information to a public health authority (such as Adult Protective Services within Maine’s Department of Health and Human Services) that is authorized by law to receive reports of actual or suspected abuse, neglect, and exploitation of children and incapacitated or dependent adults.

• Victims of Domestic Violence and Victims of Sexual Assault: We may disclose your protected health information to appropriate authorities if you are a victim of domestic violence or sexual assault and certain legal requirements are met under state and federal law.

• Health Oversight Activities: We may use and disclose your protected health information to a health oversight agency for activities authorized by law such as compliance with health oversight audits, investigations, and inspections. Oversight agencies authorized to receive your information include government agencies that oversee the health care system, government benefit programs, and other government regulatory programs, including the Maine Department of Health and Human Services, the federal Medicare program, Maine’s MaineCare program, and Maine health care professional licensing boards.

• Legal and Administrative Proceedings: We may disclose your protected health information in judicial or administrative proceedings when required or authorized by law, for example, in response to an order of a court or pursuant to a subpoena served by a governmental entity authorized by law to access your health information.

• Law Enforcement: We may disclose your protected health information for certain law enforcement purposes, so long as applicable legal requirements are met, such as to report crimes committed on HSM’s premises or against HSM personnel.

• Coroners and Medical Examiners: We may use and disclose protected health information to coroners and medical examiners regarding a deceased patient for identification purposes, or for a coroner or medical examiner to determine the cause of death or to perform other duties authorized by law.

• Funeral Directors: We may use and disclose protected health information to funeral directors consistent with applicable law as necessary to carry out their duties with respect to making funeral arrangements for a deceased patient. If necessary to carry out such duties, we may disclose such information prior to and in reasonable anticipation of a patient’s death.

• Organ, Eye or Tissue Donation: We may use and disclose protected health information to organ procurement organizations or other entities for cadaveric, organ, eye, or tissue donation purposes.

• Research: We may use and disclose your protected health information for research purposes so long as the research and any uses and disclosures related to such research are approved by an Institutional Review Board or a Privacy Board and no identifying information is disclosed in any report arising from or published in connection with the research.

• Uses and Disclosures to Avert Threats of Harm or Safety: We may use and disclose your protected health information when necessary to avert or lessen a direct threat of serious, imminent harm to health or safety.

• Specialized Government Functions: We may disclose your protected health information for certain specialized government functions relating to military, veterans, national security, intelligence, and secret service activities, medical suitability determinations, and inmates and law enforcement custody, when such disclosures are authorized or required by applicable law.

• Workers’ Compensation: We may disclose your protected health information when necessary to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness without regard to fault.

Uses and Disclosures of Protected Health Information Requiring Your Written Authorization

Written Authorization: For other types of uses and disclosures not described above, we will obtain your written authorization before using or disclosing your protected health information. For example, the following uses and disclosures require your written authorization:

• Marketing: We will obtain your written authorization for any use or disclose of your protected health information to sell or market services or products, except in limited authorized circumstances (e.g., faceto-face communications to you).

• Sale of Health Information: We will obtain your written authorization for any disclosure of your protected health information that involves a sale of your protected health information, unless an exception applies under applicable law.

• Photographs and Recordings: We will not photograph or audio or video record you, or use or disclose any photographs and recordings of you, for non-treatment related purposes or for marketing or public relations purposes, without your written authorization, unless the creation, use or disclosure of such photographs or recordings are authorized by law (e.g., for facility security surveillance purposes).

Right to Revoke Authorization: You may revoke your authorization at any time, to the extent that HSM or others have not already relied upon your authorization, by giving written notice of your revocation to HSM’s Privacy Officer.

Special Protections for Certain Types of Health Information

Confidentiality of HIV Information: If any information regarding your HIV status (such as HIV test results or medical records containing HIV information) is maintained by HSM, such information is afforded heightened protection under Maine law and we will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by Maine’s HIV confidentiality laws.

Confidentiality of Substance Use Disorder Program Information: If HSM acquires from another provider or facility any information about you that is subject to the heightened federal confidentiality protections afforded to certain substance use disorder program records under 42 C.F.R. Part 2, HSM will maintain the confidentiality and privacy of such information, and will not use or disclose such information, except as specifically authorized or required by 42 C.F.R. Part 2. If HSM acquires or maintains any substance abuse information about you that is not from a Part 2 substance use disorder program, HSM will protect the confidentiality of such information in the same way in which it protects your other protected health information.

Your Rights

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

• You have the right to access, inspect and copy your protected health information. You may inspect at reasonable times and obtain a copy of your clinical records and billing records within 30 business days of receipt of your written request. You have the right to receive your health information in the form and format of your choosing, if such information can be easily produced in such form and format, or in a readable hardcopy form, or in another format agreed to between you and HSM. If HSM maintains your health information in an electronic health record, you have the right to obtain a copy of your health information in an electronic format and to direct HSM to transmit an electronic copy of your protected health information directly to another clearly specified entity or person of your choice. You may be charged reasonable costs (including labor and supplies) associated with providing copies of your records, or of preparing any summaries that you request. In certain limited circumstances, you may be denied access to your health information and records. However, a decision to deny you access to your information and records may be reviewed. Please contact our Privacy Officer if you have questions about access to your medical records.

• You have the right to request a restriction on certain uses and disclosures of your protected health information. For example, you may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. If you request that HSM not disclose your health information to a health plan or third-party payor for purposes of carrying out payment or healthcare operations, and you have paid HSM in full for the services provided to you related to such information, HSM is required to honor your requested restriction. Otherwise, HSM is not required to agree to a requested restriction and has sole discretion to decide whether to honor a requested restriction on a case-by-case basis. If HSM agrees to a requested restriction, HSM will not use or disclose your information in violation of your restriction, unless the use or disclosure is needed to provide emergency treatment. Your request for a restriction must state the specific restriction requested and to whom you want the restriction to apply. Disclosures of protected health information authorized by you or permitted or required by law as described in this Notice, may include disclosures of protected health information HSM has received from other healthcare providers and facilities, unless you request and HSM agrees to a requested restriction on the disclosure of such information.

• You have the right to request to receive confidential communications of protected health information from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may place conditions on such accommodations, for example, by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make such requests to us in writing to our Privacy Officer.

• You have the right to submit amendments, corrections and clarifications to your protected health information. You may request amendments, corrections and clarifications to your health care information contained in your records. Your request must be in writing and you must provide a reason supporting your request. If you are requesting a change to the information in your treatment record, we will place your requested amendment, correction or clarification in your record. We may add a response to your record and will provide to you a copy of our response. If you are requesting a change in other records (that are neither medical nor billing records), we may deny your request. If your request is denied, we will notify you in writing and provide our reasons for the denial. You have the right to file a statement of disagreement with our Privacy Officer and we may prepare a response to your statement. We will provide you with a copy of our response. Please contact our Privacy Officer if you have questions about changing your health information.

• You have the right to receive an accounting of certain disclosures. You have the right to receive an accounting of certain disclosures of your protected health information made by HSM in the six years prior to the date of your request. The accounting will not include disclosures made directly to you, disclosures made to others pursuant to your written authorization, disclosures made to carry out treatment, payment, and healthcare operations for which your written authorization was not required, incidental uses and disclosures, and uses and disclosures for which an accounting is not required by law. However, disclosures made for purposes of treatment, payment, or healthcare operations through an electronic health record during the three years prior to your request will be included in an accounting. To request an accounting of disclosures of your health information, contact our Privacy Officer.

• You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically. Copies of this Notice are also available at our Gosnell Memorial Hospice House facility, located at 11 Hunnewell Road, Scarborough, Maine 04074, and on our website at www.hospiceofsouthernmaine.org.

• You have the right to file a complaint. You have the right to file a complaint with HSM or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by HSM. You may file a complaint with us by notifying our Privacy Officer listed on the first page of this Notice of Privacy Practices. HSM will not retaliate against you in any way for filing a complaint.

For More Information

If you have any questions about this Notice, or would like more information about our privacy practices, please contact our Privacy Officer:

Privacy Officer
Hospice of Southern Maine
390 US Route 1
Scarborough, Maine 04074
(207) 289-3640

This site is part of the Hospice of Southern Maine network. Below is information about the privacy and data collection practices for Hospice of Southern Maine websites, including this one.

You can visit these websites without telling us who you are or providing any information about yourself. Hospice of Southern Maine only collects the information necessary to facilitate your participation in related activities such as events and fundraising campaigns, respond to your requests for information and/or when you wish to contact us. In such instances, we may ask for your name, e-mail address, and other appropriate information needed to provide you with these services.

If you choose to give us personal information for any of the purposes above, this information is retained by Hospice of Southern Maine and may be used by us to support your customer relationship with us. However, we do not share, rent, or sell this information to other companies. You will always be able to ask us to remove your name from our mailing lists.

If you want to take your name off a Hospice of Southern Maine mailing list, or wish to update your information (e.g., change your email address), you may do so at any time. Whenever you request, we will remove your personal information from future mailings and eMailings made by us. To request having your name removed from future mailings of this type, or to update your information, please contact us at the addresses or phone number listed below.

Hospice of Southern Maine websites may provide links to other sites. Other Internet sites and services have separate privacy and data collection practices. Once you leave our website, we have no control or responsibility over the privacy policies or data collection activities at another site.

Additionally, Hospice of Southern Maine websites may use Google Analytics to help analyze how users use the website. The tool uses "cookies” to collect standard Internet log information and visitor behavior information in an anonymous form. The information generated by the cookie about your use of the website (including IP address) is transmitted to Google. This information is then used to evaluate visitors' use of the website and to compile statistical reports on website activity. For more information visit Google Analytics privacy practices in this regard.

Hospice of Southern Maine may from time to time revise its website privacy policy. To keep abreast of any such revisions you should visit this page periodically for any updates. If you have any questions about our privacy policy, the practices of this website, or your dealings with Hospice of Southern Maine websites you can write, phone or email us at the address below:

Hospice of Southern Maine
390 US Route One
Scarborough, ME 04074
Tel: (207) 289-3640
Fax: (207) 883-1040
Info@hospiceofsouthernmaine.org

(rev 12/2021)