Notice of Privacy

Cornerstone Hospice & Palliative Care, Inc.
Effective Date: April 14, 2003
Revised: June 26, 2013

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.

Who Will Follow This Notice

This notice describes Cornerstone Hospice & Palliative Care, Inc., (“Hospice”) practices and that of (a) any health care professional authorized to enter information into your medical record, (b) volunteers we allow to help you while you are receiving Hospice care, (c) all Hospice employees and staff, and (d) physician staff providing care under arrangement with Hospice. In addition, we have many doctors and other providers giving care to our patients in other locations with whom we contract such as hospitals, skilled nursing facilities and assisted living facilities. For convenience of our patients, we are giving one Notice of Privacy Practices to each patient, instead of notices from multiple physicians and other caregivers. This Notice serves as the notice required under Federal law to be given to patients by Hospice, all members of our Hospice medical staff and all other health care professionals who treat you at any of our locations. The health care providers covered by this “organized health care arrangement” (“OHCA”) will share protected health information with each other, as necessary to carry out your treatment, payment for treatment, and health care operations relating to the OHCA. This arrangement does not mean that the persons participating in the OHCA are involved in a joint business arrangement, or that they are responsible for the acts of one another.

Use And Disclosure Of Health Information

Hospice may use your health information for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Unless otherwise indicated, your health information may be used or disclosed only after Hospice has obtained your written consent or authorization. Hospice has established a policy 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. Hospice may use your health information to coordinate care within Hospice and with others involved in your care, such as your attending physician, members of thebHospice interdisciplinary team and other health care professionals who have agreed to assist Hospice in coordinating your care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. With your consent, the Hospice also may disclose your health care information to individuals outside of Hospice involved in your care including family members, clergy whom you have designated, pharmacists, suppliers of medical equipment or other health care professionals that Hospice uses in order to coordinate your care.

To Obtain Payment. With your consent, Hospice may include your health information in invoices to collect payment from third parties for the care you may receive from Hospice. For example, Hospice may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Hospice. 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.

To Conduct Health Care Operations. Hospice may use and disclose health care information for its own operations in order to facilitate the function of Hospice and as necessary to providequality care to all of Hospice’s patients. Health care operations include such activities as: (a) Quality assessment and improvement activities; (b) Protocol development, case management and care coordination; (c) Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment; (d) Professional review and performance evaluation; (e) Training programs including those in which students, trainees or practitioners in health care learn under supervision; (f) Accreditation, certification, licensing or credentialing activities; (g) Auditing, including compliance reviews, medical reviews, legal services and compliance programs; and (h) Business management and general administrative activities of the Hospice.

For example, Hospice may use your health information to evaluate its staff performance, combine your health information with other Hospice patients in evaluating how to more effectively serve all Hospice patients, disclose your health information to Hospice staff and contracted personnel for training purposes.

Hospice Directory. Hospice may disclose certain information about you including your name, your general health status, your religious affiliation and where you are in the Hospice facility in a Hospice directory while you are in the Hospice inpatient facility. 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.

Appointment Reminders. We may use and disclose health information to contact you with a reminder regarding a visit to you. reatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives.

For Fundraising Activities. Hospice may use information about you including your name, address, phone number, and the dates you received care at Hospice in order to contact you or your family to raise money for Hospice. Hospice may also release this information to an affiliated Hospice foundation. If you do not want Hospice or its affiliates to contact you for our fundraising and you wish to opt out of these contacts, you must call or email our Privacy Officer at 1-888-728-6234.

Federal Privacy Rules Allow Hospice To Use Or Disclose Your Health Information Without Your Consent Or Authorization For A Number Of Reasons Including The Following:

When Legally Required. Hospice will disclose your health information when it is required to do so by Federal, State or local law.

When There Are Risks To Public Health. Hospice may disclose your health information for public activities and purposes in order to: (a) 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; (b) 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; (c) To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease; or (d) To an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence. Hospice is allowed to notify government authorities if Hospice believes a patient is the victim of abuse, neglect or domestic violence. Hospice will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities. 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. 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. 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.

For Law Enforcement Purposes. Hospice may disclose your health information to a law enforcement official for law enforcement purposes (a) 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; (b) For the purpose of identifying or locating a suspect, fugitive, material witness or missing person; (c) Under certain limited circumstances, when you are the victim of a crime; (d) To a law enforcement official if Hospice has a suspicion that your death was the result of criminal conduct including criminal conduct at Hospice; or (e) In an emergency in order to report a crime.

To Coroners And Medical Examiners. 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.

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

For Organ, Eye Or Tissue Donation. 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 tissues for the purpose of facilitating the donation and transplantation.

For Research Purposes. Hospice may, under very select circumstances, use your health information for research. Before Hospice discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Hospice will ask your permission if any researcher will be granted access to your individually identifiable health information.

In The Event Of A Serious Threat To Health Or Safety. Hospice may, consistent with applicable law and ethical standards of conduct, disclose your health information if 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.

Military And Veterans. If you are a member of the Armed Forces, Hospice may release health information about you as required by military command authorities. Hospice may also release health information about foreign military personnel to the appropriate foreign military authority.

National Security And Intelligence Activities. Hospice may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services For The President And Others. Hospice may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, Hospice may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the correctional institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

For Worker’s Compensation. The Hospice may release your health information for worker’s compensation or similar programs providing benefits for work related injuries or illnesses.


Most uses and disclosures of psychotherapy notes, uses and disclosures of health information for marketing purposes and disclosures that constitute the sale of health information require your written authorization. Other uses and disclosures of your health information that are not described above will be made only with your written authorization. If you or your representative authorizes Hospice to use or disclose your health information, you may revoke that authorization in writing at any time. If you revoke your permission, Hospice will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that Hospice is unable to take back any disclosures that have already been made with your authorization, and that Hospice is required by law to retain our records of the care provided to you.

Your Rights With Respect To Your Health Information

You have the following rights regarding your health information that Hospice maintains:

Right To Request Restrictions. You have the right to request a restriction or limitation on the health information Hospice uses or discloses about you for treatment, payment or health care operations, and to request a limit on the health information Hospice discloses about you to someone who is involved in your care or payment, such as a family member or friend. . We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer. If Hospice does agree, however, Hospice will comply with your request unless the information is needed to provide you with emergency or other vital treatment. To request restrictions, you must tell Hospice (1) what information you want to limit (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosure to your spouse. To request restrictions, you must submit your request in writing to our Privacy Officer at the address shown below.

Right To Receive Confidential Communications. You have the right to request, in writing, that Hospice communicate with you in a certain way. For example, you may ask that Hospice only conduct communications pertaining to your health information with you privately with no other family members present. Hospice will not require that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.

Right To Inspect And Copy Your Health Information. You have the right to inspect and copy health information about you. Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in a civil, criminal or administrative action or proceeding. To inspect and copy health information, you must submit your request in writing. If you request a copy of your health information, Hospice may charge a reasonable fee for copying and assembling costs associated with your request.

Right To Amend Health Care Information. If you believe the health information we have about you is incorrect or incomplete, you may ask us to amend the information. That request may be made as long as the information is kept by or for Hospice. A request for an amendment of records must be made in writing. We may deny the request if your request for an amendment is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the health information kept by or for Hospice; (c) is not part of the information which you would be permitted to inspect and copy; or (d) is accurate and complete.

Right to an Accounting. You have the right to request an accounting (list) of certain types of disclosures we have made of your health information. We are not required to account for certain disclosures such as: (a) disclosures you authorize; (b) disclosures to carry out treatment, payment and healthcare operations; and (c) disclosures to persons involved in your care. The request for an accounting must be made in writing to our Privacy Officer. Your request must state a time period, which may not be longer than six years, and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. There may be a charge for additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of unsecured protected health information involving your medical information.

Right To A Paper Copy Of This Notice. You have a right to a paper copy of this notice anytime. You may also obtain a copy of the current version of Hospice’s Notice of Privacy Practices at our website:

Duties Of The Hospice

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. Hospice is required to abide by terms of this Notice as may be amended from time to time. 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 Hospice changes its Notice, Hospice will post a revised copy of the current notice at each of the Hospice facilities and on its website reflecting its effective date.


If you believe your privacy rights have been violated, you may file a complaint with Hospice or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Hospice contact the Privacy Officer designated below. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Contact Person

Privacy Officer or Designee

Cornerstone Hospice & Palliative Care, Inc.
2445 Lane Park Road
Tavares, FL 32778