This notice is to let you know how medical information about you may be used and disclosed. It also explains how you can get access to your health information. Please read it carefully.

Protecting Your Health Information:

HomeCentris Home Health, LLC (HHH), a subsidiary of HomeCentris Healthcare, LLC (HomeCentris), is committed to protecting your health information. So that we can provide services or bill under various state and federal programs, HHH will ask you for information about your health. This request may be for information about your medical condition, medications, and physical or mental abilities. This information will be maintained in your file at HHHs office or on its secure computer network. HHH must follow the privacy practices in this Notice. HHH may change its privacy practices and this Notice from time to time as our policies or privacy regulations change. Our most recent privacy notice will be on our website and you may ask HHH for a copy of the latest privacy notice at any time.

Uses and disclosures of health information required or allowed by law:

HHHs staff and contractors will only use your health information when doing their jobs. Some examples of the uses and disclosures of your health information are:

To provide services: HHH may use or share your health information in the course of providing services to you. Information may be shared with other healthcare providers serving you, such as your physician(s) or other members of your healthcare team, representatives of federal and state healthcare agencies, or other private organizations currently involved in your healthcare. Information may also be shared with your family or friends who provide care, if you so designate.
In addition, we have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may opt-out and disable all access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at Public Health reporting and Controlled Dangerous Substances information as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

For Payment: HHH may need to use medical information about you so we may invoice payors such as Medicare, Medicaid, or an insurance company for the services you receive. This may not be necessary depending on your circumstances or if we are billing you directly. We are permitted by law to disclose the amount of medical information necessary for us to obtain payment for the care and services provided to you. Our disclosure of medical information for obtaining payment, may also include our giving information to your family members who are involved in you care, who are included on your health insurance, or who help pay for your care.

For Health Care Operations: We may use and disclose medical information about you for HHH management decisions. This may be necessary to run HHH and to make sure all of our clients receive quality care. For example, we may use your information to review our services and to evaluate the qualifications and performance of our staff in caring for you. We may also combine medical information about many HHH patients to decide what additional services we should offer, what services are not needed, and whether improvements can be made.

To provide statistical information under state or federal programs: HHH may use or share your health information in general terms while reporting statistical information under state or federal programs. This may include oversight agencies who perform audits, investigations, inspections and/or license renewal activities.

When required by law: HHH may disclose health information when the law says we must such as a court-ordered subpoena or in the reporting of communicable disease, for public health activities or other public safety reasons.

Other personal information: HHH will not voluntarily share any facts that identify you with anyone except people who need the facts to perform their jobs. Facts that identify you include your name, social security number, address and telephone number.

You have a Right to:

Request restrictions: You have a right to ask HHH to restrict the health information we use or disclose about you. HHH will honor your request if possible, although we are not required by law to do so. If HHH agrees to a restriction, we will follow it except in emergency situations.

Request confidential communications: You have the right to ask HHH to send you information at a different address or in a different way. We must agree to do so, if it is reasonably easy.

Inspect and Copy: You have a right to see your health information when you request it in writing. If you want copies of your health information, you must complete a HIPAA request form and we will charge you a reasonable fee of $1.00 per page for copying. You have a right to choose what parts of your information you would like copied and to know the cost of the project before we make copies.

Request amendment: You may ask HHH to correct or add to your health record by writing to us. HHH may deny the request if we decide (1) the original health information is correct and complete; (2) the health information you are requesting to change was not created by HHH and is not part of HHHs records; or (3) the health information may not be disclosed. If HHH agrees with the requested changes, we will change your record and let you know. We will also tell others who need to know about the change in the health information.

Get a list of disclosures: You have a right to ask for a list of the disclosures of your health information. Exceptions are: (l) health information that has been used for treatment; (2) disclosures that we made to you, or were based on your written authorization; (3) disclosures to law enforcement officials or to correctional facilities. There will be no charge for up to one of these lists each year.

This Notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by email.

Refuse to provide some or all of the information requested:You have a right to refuse to give some or all of the information requested. HHH staff can tell you exactly which facts are needed for us to provide service.

To Report a Problem about our Privacy Practices:

If you believe your privacy rights have been violated, you may file a complaint.
• You can file a complaint with the HHH office.
• You can file a complaint with the Secretary of the U.S., Department of Health and Human Services, Office of Civil Rights.
HHH will take no retaliatory action against you if you make a complaint.

For Further information or questions contact the HHH office at 410-486-8303.

I confirm that I have received this notice:

Patient or Authorized Representative:____________________ Date:______________

Signature of HHH representative: ______________________ Date: ______________