NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
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.
This Notice describes the privacy practices of Envision Home Health LLC, dba Envision Home Health
and Hospice, dba Envision Hospice. We are committed to maintaining your confidentiality and
protecting your health information.
This Notice describes your rights and our duties regarding your Protected Health Information related to
the care and services we provide to you in our facilities, other health care and residential facilities and
your home. It also applies to our health care professionals including but not limited to physicians, nurses,
and aides that provide care to you. Each provider will follow the terms of this Notice and we will use and
share your Protected Health Information with each other, as necessary, for the purposes of treatment,
payment, and health care operations.
Our agency is required by law to maintain the privacy of protected health information, to provide you
adequate notice of your rights and our legal duties and privacy practices with respect to protected health
information and to notify affected individuals following a breach of unsecured protected health
information. [45 CFR §164.520] We will use or disclose protected health information in a manner that is
consistent with this notice.
The agency maintains a record (paper/electronic file) of the information we receive and collect about you
and of the care we provide to you. This record includes physicians’ orders, assessments, medication lists,
clinical progress notes and billing information.
As required by law, the agency maintains policies and procedures about our work practices, including
how we coordinate care and services provided to our patients. These policies and procedures include how
we create, receive, access, transmit, maintain and protect the confidentiality of all health information in
our workforce and with contracted business associates and/or subcontractors; security of the agency
building and electronic files; and how we educate staff on the privacy of patient information.
As our patient, information about you must be used and disclosed to other parties for purposes of
treatment, payment, and health care operations . Examples of information that must be disclosed:
● Treatment: Providing, coordinating or managing health care and related services, consultation
between health care providers relating to a patient or referral of a patient for health care from one
provider to another. For example, we meet on a regular basis to discuss how to coordinate care
for patients and to schedule visits.
● Payment: Billing and collecting for services provided, determining plan eligibility and coverage,
utilization review (UR), precertification, medical necessity review. For example, occasionally the
insurance company requests a copy of the medical record be sent to them for a coverage review
prior to paying the bill.
● Health Care Operations: General agency administrative and business functions, quality
assurance/improvement activities; medical review; auditing functions; developing clinical
guidelines; determining the competence or qualifications of health care professional; evaluating
agency performance; conducting training programs with students or new employees; licensing,
survey, certification, accreditation and credentialing activities; internal audit; and certain
fundraising activities and with your authorization, marketing activities. For example, our agency
periodically holds clinical record review meetings where the consulting professional of our record
review committee will audit clinical records for meeting professional standards and utilization
The following uses and disclosures do not 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 diseases such as Human Immunodeficiency Virus (HIV) and Acquired
Immunodeficiency 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 as
permitted by state law 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 us 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 provide you care;
6. Licensing and accrediting bodies, including the information contained in the OASIS Data Set to
the state agency acting as a representative of the Medicare/Medicaid program;
7. Contact you to raise funds for the Agency; you will be given the right to opt out of receiving such
8. Any business associate or institutionally related foundation for the purpose of raising funds for
the agency (information may include; demographics – name, address, contact information, age
gender, date of birth; dates of health care provided; department of services; treating physician;
outcome information; and health insurance status). You will be given the right to opt out;
9. Refill reminders for drug, biological and /or drug deliver systems that have already been
prescribed to you;
10. Marketing communications promoting health products, services and information if the
communication is made face to face with you or the only financial gain consists of a promotional
gift of nominal value provided by the agency; and
11. Other health care providers to initiate treatment.
We are permitted to use or disclose information about you without consent or authorization in the
1. In emergency treatment situations , if we attempt to obtain consent as soon as practicable after
2. Where substantial barriers to communicating with you exist and we determine that the consent
is clearly inferred from the circumstances;
3. Where we are required by law to provide treatment and we are unable to obtain consent;
4. Where the use or disclosure of medical information about you is required by federal, state or
local law ;
5. To provide information to state or federal public health authorities , as required by law to :
prevent or control disease, injury or disability; report births and deaths; report child abuse or
neglect; report reactions to medications or problems with products; notify persons of recalls of
products they may be using; notify a person who may have been exposed to a disease or may be
at risk for contracting or spreading a disease or condition; and notify the appropriate government
authority if we believe a patient has been the victim of abuse, neglect or domestic violence (if you
agree or when required or authorized by law);
6. Health care oversight activities such as audits, investigations, inspections and licensure by a
government health oversight agency as authorized by law to monitor the health care system,
government programs and compliance with civil rights laws;
7. To business associates regulated under HIPAA that work on our behalf under a contract that
requires appropriate safeguards of protected health information;
8. Certain judicial administrative proceedings in response to a court or administrative order, a
subpoena, discovery request or other lawful process by someone else involved in the dispute, but
only if efforts have been made to tell you about the request or to obtain an order from the Court
protecting the information requested;
9. Certain law enforcement purposes such as helping to determine whether a crime has occurred,
to alert law enforcement to a crime on our premises or of your death if we suspect it resulted from
criminal conduct, identify or locate a suspect, fugitive, material witness or missing person, or to
comply with a court order or subpoena and other law enforcement purposes.
10. To coroners, medical examiners and funeral directors, in certain circumstances, for example
to identify a deceased person, determine the cause of death or to assist in carrying out their duties;
11. For cadaveric organ, eye or tissue donation purposes to communicate to organizations
involved in procuring, banking or transplanting organs and tissues (e.g., if you are an organ
12. For certain research purposes under very select circumstances. We may use your health
information for research. Before we disclose any of your health information for such research
purposed, the project will subject to an extensive approval process. We will usually request your
written authorization before granting access to your individually identifiable health information;
13. To avert a serious threat to health and safety: To prevent or lessen a serious and imminent
threat to the health or safety of a particular person or the general public, such as when a person
admits to participation in a violent crime or serious harm to a victim or is an escaped convict.
Any disclosure, however, would only be to someone able to help prevent the threat;
14. For specialized government functions , including military and veterans’ activities, national
security and intelligence activities, protective services for the President, foreign heads of state and
others, medical suitability determination, correctional institution and custodial situations; and
15. For Workers’ Compensation purposes : Workers’ compensation or similar programs provide
benefits for work-related injuries or illness.
We are permitted to use or disclose information about you provided you are informed in advance
and given the opportunity to individually agree to, prohibit, opt out or restrict the disclosure in the
1. Use of a directory (includes name, location, condition described in general terms) of individuals
served by our Agency;
2. Provide proof of immunization to a school that is required by state or other law to have such
proof with agreement to disclosure by parent, guardian or other person acting in loco parentis if
record is of an unemancipated minor; and
3. Provide a family member, relative, friend or other identified person, prior to, or after your death,
the information relevant to such person’s involvement in your care or payment for care; to notify a
family member, relative, friend or other identified person of your location, general condition or
Other uses and disclosures not covered in this notice will be made only with your authorization.
Authorization may be revoked, in writing, at any time, except in limited situations for the following
1. Marketing of products or services or treatment alternatives that may be of benefit to you when we
receive direct payment from the third party for making such communications;
2. Psychotherapy notes under most circumstance, if applicable; and
3. Any sale of protected health information resulting in financial gain by the agency unless an
exception is met.
YOUR RIGHTS – You have the right, subject to certain conditions, to:
● Request restrictions on uses and disclosures of your protected health information for
treatment, payment or health care operations; however, we are not required to agree to any
requested restriction. Restrictions to which we agree will be documented. Agreements for further
restrictions may, however be terminated under applicable circumstances (e.g. emergency
We must agree to your request to restrict disclosure of protected health information about you to a health
plan if: 1) the disclosure is for the purpose of carrying out payment or health care operations and is not
otherwise required by law; and 2) the protected health information pertains solely to a health care item or
service for which you or someone on your behalf paid the covered entity in full. (164.522 Rights to
request privacy protection for protected health information).
● Confidential communication of protected health information. We will arrange for you to
receive protected health information by reasonable alternative means or at alternative locations.
Your request must be in writing. We do not require an explanation for the request as a condition
of providing communications on a confidential basis and will attempt to honor reasonable
requests for confidential communication.
If you request your protected health information to be transmitted directly to another person designated by
you, your written request must be signed and clearly identify the designated person and where the copy of
protected health information is to be sent.
● Inspect and obtain copies of protected health information that is maintained in a designated
record set, except for psychotherapy notes, information compiled in reasonable anticipation of, or
for use in, a civil, criminal or administrative action or proceeding, or protected health information
that may not be disclosed under the Clinical Laboratory Improvements Amendments of 1988 [42
USC §263a and 45 CFR § 493 (a)(2)]. If you request a copy of your health information, we will
charge a reasonable, cost-based fee that includes only the cost of labor for copying, supplies and
postage, if applicable, in accordance with applicable state and federal regulations.
If the request protected health information is maintained electronically and you request an electronic
copy, we will provide access in an electronic format you request, if readily producible, or if not, in a
readable electronic form and format mutually agreed upon.
If we deny access to protected health information, you will receive a timely, written denial in plain
language that explains the basis for the denial, your review rights and an explanation of how to exercise
those rights. If we do not maintain the medical record, we will tell you where to request the protected
● Request to amend protected health information for as long as the protected health information
is maintained in a designated record set. A request to amend your record must be in writing and
must include a reason to support the requested amendment. We will act on your request within
sixty (60) days of receipt of the request. We may extend the time for such action by up to 30
days, if we provide you with a written explanation of the reasons for the delay and the date by
which we will complete action on the request.
We may deny the request for amendment if the information contained in the record was not created by us,
unless you provide a reasonable basis for believing the originator of the information is no longer available
to act on the requested amendment; is not part of the designated medical record set; would not be
available for inspection under applicable laws and regulation; or the record is accurate and complete. If
we deny your request for amendment, you will receive a timely, written denial in plain language that
explains the basis for the denial, your rights to submit a statement disagreeing with the denial and
explanation of how to submit that statement.
● Receive an accounting of disclosures of protected health information made by our Agency for
up to six (6) years prior to the date on which the accounting is requested for any reason other than
for treatment, payment or health operations and other applicable exceptions. The written
accounting includes the date of each disclosure, the name/address (if known) of the entity or
person who received the protected health information, a brief description of the information
disclosed and a brief statement of the purpose of the disclosure or a copy of the written request
for disclosure. We will provide the accountings within 60 days of receipt of a written request;
however, we may extend the time period for providing the accounting by 30 days if we provide
you with a written statement of the reasons for the delay and the date by which you will receive
the information. We will provide the first accounting you request during any 12-month period
without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
● Receive notification of any breach in the acquisition, access, use or disclosure of unsecured
protected health information by the agency, its business associates, and/or subcontractors.
● Obtain a paper copy of this notice , even if you had agreed to receive this notice electronically,
from us upon request.
COMPLAINTS – If you believe that your privacy rights have been violated, you may complain to the
Agency or to the Secretary of U.S. Department of Health and Human Services. 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 be filed in writing within 180 days of when the act or omission complained of occurred, and must
describe the acts or omissions believed to be in violation of applicable requirement. [45 CFR § 160.306]
For further information regarding filing a complaint, contact: Sherie Stewart, Envision Home Health
and Hospice, 1345 W 1600 N #202, Orem, UT 84057; Phone: (801) 225-7971 .
EFFECTIVE DATE – This notice is effective February 23, 2014. We are required to abide by the terms
of the notice currently in effect, but we reserve the right to change these terms as necessary for all
protected health information that we maintain. If we change the terms of this notice (while you are
receiving service), we will promptly revise and distribute a revised notice to you as soon as practicable by
mail, email (if you have agreed to electronic notice, hand delivery or by posting on our website.
If you have any questions about this Notice or would like further information concerning your
privacy rights, contact our Privacy Officer at:
Sherie Stewart, COO
Envision Home Health LLC
1345 W 1600 N #202
Orem, UT 84057
Phone: (801) 225-7971
Toll-free: (866) 471-5733
Effective Date of this Notice: September 16, 2013
Revised Date: February 23, 2014