HIPAA Notice

It is the policy of Hospice of Westchester that authorizations be required for the use and disclosure of a patient’s Protected Health Information for the purpose other than treatment, payment and health care operations.

Hospice of Westchester ensures that the Medical Record is maintained in a manner that is consistent with legal requirements.

Medical information will not be disclosed without the consent of the patient and/or the patient’s representative.

Hospice of Westchester utilizes an Electronic Medical Record for most of its PHI. Federally required paper Hospice records are kept in a locked secure area of the Hospice offices and archived paper records are stored in an offsite secure facility. Only authorized personnel may access either set of records for the purpose of program monitoring, continuity of care, continuous quality improvement or reimbursement of services. Only employees who are directly involved in the provision of the above services may view these records.

All patients and/or designated representatives have the ability to review, inspect and/or obtain a copy of the PHI which is kept in the Electronic Medical Record. When a patient/patient’s representative requests access to his/her Hospice record, the Director of Performance Improvement or designated representative will inform the patient/patient’s representative of his/her options.

Patients or designated representatives may request a copy of their Medical Record by completing and signing an “Authorization for Release of Health Information Pursuant to HIPPA” form. All patients or designated representatives Medical Record requests must be acted upon within 10 business days. Signed authorization is not needed to use or disclose PHI for:

  • Hospice treatment, payment and/or health care operations;
  • Treatment activities of another health care provider;
  • Payment activities of the entity to which PHI is disclosed, and
  • Health care operations of another entity if;
    • Both Hospice and the other entity has or has had a relationship with the individual and the PHI involved pertains to that relationship; and/or
    • The disclosure is for specific health care operation purposes (including quality assessment and improvement activities, case management or care coordination, training, accreditation or licensing activities) or fraud and abuse detention or compliance.

The HIPPA Privacy Rule requires Hospice to act upon a patient’s request to amend PHI due to their belief that the information is incorrect or erroneous. All such requests will be kept in a dedicated part of the Medical Record. Requests for amendments to PHI must be acted upon with 60 days of the written receipt of request. Up to an additional 30 day extension is allowable if Hospice of Westchester is unable to act on the request within the deadline, but Hospice of Westchester must provide the patient with a written reason for the delay and the date by which Hospice will complete the action.

Hospice of Westchester’s “Notice of Privacy Practices”, informs our patients of their rights under HIPAA’s Privacy Rule to file a complaint with Hospice of Westchester’s Compliance Officer and the Office of Civil Rights (OCR) when they have reason to believe their privacy rights have been violated.

The Compliance Officer or appointed Committee designee will take all complaints and/or allegations of non-compliance seriously and will fully investigate the allegations to determine what course of corrective action, if any, needs to be taken. The Compliance Officer or appointed designee will notify the patient in writing the outcome of the investigation and what corrective action, if any, was taken within 60 days.

Further questions may be directed to the Director of Clinical Services, Carol Townsend Ross at 914-682-1484 ext. 135; or the Chief Executive Officer, Mary Spengler at 914-682-1484, ext. 112.