COLUMBIA MONTOUR HOME HEALTH SERVICES
VISITING NURSES ASSOCIATION, INC.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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.

The Visiting Nurses Association (VNA) is required by law to maintain the privacy of protected health information and to provide you with notice of its legal duties and privacy practices. The VNA must abide by the terms of the notice currently in effect, but the VNA reserves the right to change the terms. If there is a change, the VNA will provide you with a written revised notice
as soon as practicable by mail or hand delivery.

As a patient of the VNA, information about you must be used and disclosed to other parties
for purposes of treatment, payment, and health care operations. These uses and disclosures require your consent, and include, but are not limited to, a release of information contained in financial records and/or medical records, including information concerning communicable disease such as Human Immune Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory
test results, medical history, treatment progress and/or any other related information, to:

1. Your insurance company, self-funded or third-party, health plan, Medicare, Medicaid, or any other person or entity that may be responsible for paying or processing for payment any portion of your bill for services;

2. Any person or entity affiliated with or representing for purposes of administration, billing,
and quality and risk management;

3. Any hospital, nursing home, or other health care facility to which you may be admitted;

4. Any assisted living or personal care facility of which you are a resident;

5. Any physician providing you care;

6. Family members and other caregivers who are part of your home care plan for service;

7. Licensing and accrediting bodies, including the information contained in the OASIS Data Set
to the state agency acting as representative of the Medicare/Medicaid program;

8. Contact you to provide appointment reminders or information about other health activities
we provide;

9. Contact you to raise funds for the VNA.

The VNA is permitted to use or disclose information about you without consent or authorization in the following circumstances:

1. In emergency treatment situations, if the VNA attempts to obtain consent as soon as practicable after treatment;

2. Where substantial barriers to communicating with you exist and the VNA determines that the consent is clearly inferred from the circumstances;

3. Where the VNA is required by law to provide treatment and we are unable to obtain consent;

4. Where the use or disclosure is required by law;

5. For certain public health activities;

6. Where the VNA reasonably believes you are a victim of abuse, neglect, or domestic violence to a government authority authorized to receive reports of abuse, neglect or domestic violence;

7. Health care oversight activities;

8. Certain judicial administrative proceedings;

9. Certain law enforcement purposes;

10. To coroners, medical examiners and funeral directors, in certain circumstances;

11. For cadaveric organ, eye or tissue donation purposes;

12. For certain research purposes;

13. To avert a serious threat to health and safety;

14. For specialized government functions, including military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institution and custodial situations;

15. For Workers Compensation purposes.

The VNA is permitted to use or disclose information about you without consent or authorization provided you are informed in advance and given the opportunity to agree to or prohibit or restrict the disclosure in the following circumstances:

1. The use of directory of individuals served by the VNA;

2. To a family member, relative, friend, or other identified person, the information relevant to such persons involvement in your care or payment for care.

Other uses and disclosures will be made only with your written authorization. That authorization may be revoked, in writing, at any time, except in limited situations.

YOUR RIGHTS

You have the right, subject to certain conditions, to:

1. Request restrictions on certain uses and disclosures of information about you. However,
the VNA is not required to agree to the requested restriction;

2. Receive confidential communication of protected health information;

3. Inspect and copy protected health information;

4. Amend protected health information;

5. Receive an accounting of disclosures;

6. Obtain a paper copy of this notice, if you had agreed to receive this notice electronically.

COMPLAINTS

You may complain to the VNA and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing and should state the specific incident(s) in terms of subject, date, and other relevant matters. A complaint to the Secretary must comply with the standards set out in 45 CFR § 160.306.

To file a complaint with the VNA, contact:

Columbia Montour Home Health Services/VNA
Privacy Officer
410 Glenn Avenue, Suite 200
Bloomsburg, PA 17815
Phone number: 570-784-1723 or 1-800-349-4702

To file a complaint with the Secretary of Health and Human Services, contact:

Region III
Office of Civil Rights
U.S. Department of Health and Human Services
150 South Independence Mall West, Suite 372
Public Ledger Building
Philadelphia, PA 19106-9111
Main phone number: 215-861-4441 or 1-800-368-1019
Hotline: 215-861-4431 Fax
TDD: 215-861-4440