Hospice of Montezuma, Inc.


Your rights under the Health Insurance Portability & Accountability Act of 1996 (HIPAA)


If you have any questions about this notice, please contact the Hospice of Montezuma Privacy Officer at (970)565-4400

Who Will Follow This Notice of Privacy Practices (“Notice”):This Notice describes Hospice of Montezuma (the “Agency”)practices and that of:

  • Any health care professional authorized to enter information into your medical record maintained by Hospice of Montezuma
  • All departments and units of Hospice of Montezuma
  • Any member of a volunteer group allowed to help you while you are receiving services from Hospice of Montezuma
  • All employees, staff, agents, and other Hospice of Montezuma personnel
  • All entities, sites, and locations within Hospice of Montezuma will follow the terms of this Notice.  They may also share medical information with each other for treatment, payment, and health care operations purposes.

Our Pledge Regarding Medical Information:  We understand that medical information about you and your health care is personal.  We are committed to protecting medical information about you.  A medical record is created to document the care and services you receive through this Agency.  This record is needed to provide the patient care and to comply with legal requirements.  This Notice applies to all of the medical records of your care generated by the Agency.  Your personal physician may have different policies or privacy notices regarding the physician’s use and disclosure of your medical information in the physician’s office or clinic.

This notice will tell about the ways in which Hospice of Montezuma may use and disclose medical information about you.  It also describes your rights and certain obligations we have regarding the use and disclosure of medical information.

The law requires the Agency to:

  • Make sure that the medical information that identifies you is kept private;
  • Inform you of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the Notice that is currently in effect.

How Hospice of Montezuma (the “Agency”) may use and disclose your medical information:

The following categories describe different ways the Agency uses and discloses medical information.  Each category will be explained.  Not every possible use or disclosure will be listed.  However, all of the different ways the Agency is permitted to use and disclose information will fall within one of these categories.

  • Treatment:  Your medical information may be used to provide you with medical treatment or services.  This medical information may be disclosed to physicians, nurses, technicians, or other workforce members of the Agency who are involved in your care at the Agency.  Your medical information may also be disclosed to healthcare students, interns, and residents.
  • As an example:  A nurse who is assigned to provide care to you for cancer may need to know that you have diabetes because your blood sugar levels may affect your risk of falling.  The nurse may consult with a dietitian to obtain a list of nutritional supplement drinks that would be safe for you to use.
  • Payment:  Your medical information may be used and disclosed so that the treatment and services provided by the Agency may be billed and payment may be collected from your insurance company, Medicare or Medicaid, or from you.
  • As an example: Medicare, Medicaid, or your insurance company may need to know how many physical therapy or nursing visits you had, how long each visit lasted, and the services provided during that visit.  In some cases, they may need information to provide approval before a treatment begins.
  • Health Care Operations:   Your medical information may be used and disclosed for purposes of furthering day-to-day Agency operations.  These uses and disclosures are necessary to run the Agency and to monitor the quality of care our patients and their families receive.
  • As an example:  Your medical information may be reviewed during an audit of our charts by an employee who did not provide care to you.  Your information could be used to provide education to students or our staff so that they are better able to care for similar patients.  It may be used to determine when we should contact you to ask how satisfied you were with our services  It may be combined with the information from other patients to study ways to improve care or reduce health care costs.
  • Census Information:  Limited information about you may be used in the Agency census report while you are a patient of the Agency.  This information may include your name, admission date, and address.
  • Appointment Reminders and Prescription Information:  Your medical information may be used to contact you by phone or mail to remind you of the scheduled appointments from our staff or to assist you in obtaining medications and medication refills in a timely manner.  Unless you have requested that we communicate with you in a different way, we may leave messages on your answering machine/voice mail or with a family member or other person that answers the phone if you are not available or able to answer the phone.  We will make every effort to disclose only the information you have approved to have shared.
  • Treatment Alternatives:  Your medical information may be used to tell you about possible treatment options or alternatives for symptom control that may be of interest to you.
  • Benefits and Services:  Your medical information may be used to tell you about benefits or services that may be of interest to you or your family  to assist with housing, finances, or eligibility for various programs.
  • Individuals Involved in Your Care:  With your permission, your medical information may be released to a family member, guardian, or other individuals involved in your care.  They may also be told about your condition unless you have requested additional restrictions.  Your medical information may also be disclosed to an entity assisting in a disaster relief effort so your family can be notified about your condition, status, and location.
  • Fundraising:  We may use certain information (for example your name, address, or telephone number) to inform you of fundraising activities of this Agency.   Money raised is used to expand and improve the services and programs we provide to the community and to provide care for those who do not have insurance to cover the cost of their care.  You will have the right to opt out of such communications with each solicitation and your decision will have no impact on your treatment or payment for services at this Agency.
  • Research:  Under certain circumstances, your medical information may be used and disclosed for research purposes.
  • As an example:  Hospice of Montezuma has provided patients/families the opportunity to participate in research regarding caregiver support and fall prevention in the home.
  • As Required by Law:  Your medical information will be disclosed when require to do so by federal, state, or local authorities, laws, rules, and/or regulations.
  1. Lawsuits and Disputes.  If you are involved with a lawsuit or a dispute, your medical information will be disclosed in response to a court or administration order, subpoena, discovery request, or other lawful process by someone else involved in the dispute when we are legally required to respond.
  2. Law Enforcement.  Your medical information will be released if requested by a law enforcement official:
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct; and
  • In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
  1. National Security and Intelligence Activities.  Your medical information will be released to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  2. Protective Services for the President of the United States and Others.  Your medical information may be disclosed to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
  3. To Alert a Serious Threat to Health or Safety.  Your medical information may be used and disclosed when necessary to prevent a serious threat to our health and safety and that of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat.
  4. Health Oversight Activities.  Your medical information may be disclosed to a health oversight facility for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  5. Private Accreditation Organizations.  Your medical information may be used to fulfill this Agency’s requirements to meet the guidelines of private facility accreditation organizations such as The National Committee for Quality Assurance, etc.
  • Business Associates.  There are some services provided by this Agency through contracts with business associates.  Examples include information technology support services or durable medical equipment supplied to patients.  When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill us, a third party carrier, or you for the services rendered.  To protect your health information, however, business associates and subcontractors of business associates are required by  federal law to appropriately safeguard your information.
  • Future Communications.  We may communicate to you or your family members via newsletters, mail outs, or other means regarding  community based initiatives or activities, information on grief and bereavement, or quality assurance programs our agency is participating in.

Special Situations

  • Organ and Tissue Donation. If you are an organ or tissue donor, your medical information may be released to organizations that handle organ procurement or organ, eye and tissue transplantation. or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
  • HIV, Substance Abuse, Mental Health and Genetic Information.  Special privacy protections apply to HIV-related information, alcohol and substance abuse, mental health, and genetic information.  Some parts of this Notice may not apply to these kinds of protected health information.  Please check with our Agency Privacy Officer for information about the special protections that do apply.  For example, if you choose to be tested for HIV, we will not disclose the fact that you have taken the test to anyone without your written consent unless otherwise required by law.
  • Military and Veterans.  If you are a member of the armed forces, our medical information may be released as required by military command authorities.  If you are a member of the foreign military personnel, your medical information may be released to the appropriate foreign military authority. 
  • Workers’ Compensation.  If you seek treatment for a work-related illness or injury, we must provide full information in accordance with state-specific laws regarding workers’ compensation claims.  Once state-specific requirements are met and an appropriate written request is received, only the records pertaining to the work-related illness or injury may be disclosed.
  • Public Health Risk.  Your medical information may be used and disclosed for public health activities.  These activities generally include the following:
  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report child abuse or neglect;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.  We will only make this disclosure if you agree or when required or authorized by law.
  • Coroners, Medical Examiners, and Funeral Directors.  Your medical information may be released to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release medical information about patients to the facility or funeral directors as necessary to carry out their duties.
  • Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.  This release would be necessary for the following reasons:
  1. For the institution to provide you with health care;
  2. To protect the health and safety of you and others; and
  3. For the safety and security of the correctional institution.


  • Changes To This Notice:  We reserve the right to change this Notice and make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.  The Agency will distribute a current copy of the Notice with the effective date to all current patients and also post it on our website.  In addition, each time you are admitted to the Agency for care/service, we will provide you a copy of the current Notice in effect.
  • Complaints:  You will not be penalized for filing a complaint.  If you believe your privacy rights have been violated, you may file a complaint with the Agency or with the Secretary of the Department of Health and Human Services,  to file a complaint with the Agency, contact the Agency Privacy Officer and/or follow the process outlined in this Agency’s Patient Rights documentation.  All complaints must be submitted in writing.


You have the following rights regarding medical information the Agency maintains about you:

**NOTE:  All Requests to Inspect and Copy Medical Information or to Receive an Electronic Copy of the Medical Information that May be Used to Make Decisions about You Must Be Submitted in Writing to the Agency Medical Records Department.

  • Right to Inspect and Copy:  You have the right to inspect and copy medical information that is maintained by this Agency and that is used to make decisions about your care.  You also have the right to request an explanation or summary of your medical information.  If your request is approved, we have thirty (30) days in which to respond to your request.  If we are unable to respond within thirty (30) days (for example, the records you have requested are stored off site), we may request an additional thirty (30) days in which to respond to your request.  You will receive written notice of this extension, if needed, and such notice will explain the reasons for the delay and the expected date of delivery.  We will respond to the request within a reasonable amount of time but no later than sixty (60) days from the date your written request is submitted to the Medical Records Department.
  • We may deny your request to inspect and copy your medical information in some limited circumstances (see below).  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional, other than the person who denied your request, will be chosen by the Agency to review your request and the denial.  The Agency will comply with the outcome of the review.
  • If the Agency uses or maintains an electronic health record in one or more designated record sets with respect to your medical information, we must provide you with access to the electronic information in electronic form and the format requested, if it is readily producible, or, if not, in a readable form and format mutually agreed upon.  You may direct the Agency to transmit the copy to another entity or person that you designate provided the choice is clear, conspicuous, specific, and verifiable.  Your request must be submitted to the Agency Medical Records Department in writing; it must be signed by you or your Medical Power of Attorney; and it must clearly identify the designated person or persons and where to send the copy.  We will ask persons picking up records in person to present a government-issued picture I.D.
  • If you request a paper copy of the information, we may charge a fee for the cost of copying, mailing, or other supplies associated with your request.  If you request an explanation or summary of your medical information, we may charge a fee equal to the labor cost of compiling such explanation or summary.
  1. A licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of the individual or another person.
  2. The protected health information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other person.
  3. The request for access is made by the individual’s personal representative, and a licensed health are professional has determined, in the exercise of professional judgment, that the provision of access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.
  4. The information requested is not maintained by our Agency.  In such situation, if we know the location of the information requested, we must provide that information to you.
  • Right to Amend  If you  feel that medical information we have about you is incorrect or incomplete,  you may ask us to amend the information.  You have the right to request an amendment to the information kept by or for the Agency.
  • To request an amendment, you must submit a written request to the Agency Medical Records Department.  You must also provide a reason that supports your request.  Your request for an amendment may be denied if:
  1. Your request is not in writing or does not include a reason to support the request;
  2. The medical information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  3. The medical information is not part of the medial information kept by or for the Agency;
  4. The medical information is not part of the information you would be permitted to inspect and copy; or
  5. The medical information is accurate and complete.
  • Right to an Accounting of Disclosures.   You have the right to request an “accounting of disclosures.”  This is a list of the disclosures we made of your medical information for purposes other than treatment, payment, and health care operations.

To request this list or accounting of disclosures:

  1. You must submit your request in writing to the Hospice of Montezuma Medical Records Department.
  2. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.
  3. Your request should indicate in what form you want the list (for example, on paper or electronically).

The first list you request within a 12-month period will be free.  For additional lists, we may charge you for the costs of providing the list.  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 Request Restrictions.  You have a right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member.  This restriction does not apply to uses or disclosures of your health information related to your medical treatment.

To request restrictions, you must make your request in writing to the Agency Medical Records  Department.  In your request, you must tell us:

  1. What information you want to limit;
  2. Whether you want to limit our use, disclosure, or both;
  3. To whom you want the limits to apply (for example, disclosures to your spouse).

You also have a right to request that a health care item or service not be disclosed to your health plan for payment purposes or health care operations.  We are required to honor your request IF the health care item or service is paid out of pocket and in full.              Your restriction will only apply to records that relate solely to the service for which you have paid in full.

We are not required to agree to any other request and will notify you if we are unable to agree.  If we agree to your request, we must follow your restrictions (unless the information is necessary for emergency treatment).  You may cancel the restrictions at any time.  In addition, we may cancel  the restriction at any time, unless it relates to a health care item or service that is paid out of pocket and in full, as long as we notify you of the cancellation and continue to apply the restriction to information collected before the cancellation.

  • Right to Request Confidential Communication.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
  • To request confidential communications, you must, submit your request in writing to the Agency Medical Records Department or Agency Privacy Officer.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.
  • As an example:  You can ask that we only contact you at work or by mail.
  • Right to a Paper Copy of this Notice.  You have the right to a copy of this Notice.  You may ask us to give you a copy at any time.  Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
  • Right to Receive Notice of a Breach.  We are required to notify you by first class mail or by email (if you have indicated a preference to receive information by email), of any breach of your unsecured protected health information.
  • Agency Privacy Officer.  If you  have any questions about this Notice, please contact the Agency Privacy Officer at (970)565-4400.

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