Policy:

It is the policy of EverHeart Hospice to be an Equal Opportunity Employer and to employ qualified personnel without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, family medical history, genetic information, political affiliations, military services or any other classification protected by state or federal law.

Procedure:

1. It is the responsibility of each supervisor to incorporate the Equal Employment Opportunity policy of the agency in decisions to recruit, hire, transfer, train, and promote persons in all job titles without regard to anything unrelated to the performance of the job. Supervisors are to judge individual ability and performance based on job-related, nondiscriminatory factors.
2. All personnel actions such as, but not limited to, compensation, benefits, promotions, transfers, reductions in workforce, discipline, training, and education programs, will be administered without regard to anything unrelated to job performance.
3. Prohibited discrimination in the workplace by employees and supervisors shall be subject to discipline up to and including termination.

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.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

During your treatment at Hospice of Darke County, Inc. (the “Agency”), doctors, nurses, and other caregivers may gather and/or generate information about your medical history and your current health.  This Notice will explain how such information may be used and shared with others.  It will also explain your privacy rights regarding this kind of information.  The Agency is required by law to take reasonable steps to maintain the privacy of your personally identifiable protected health information (“PHI”) and to inform you regarding the Agency’s legal duties and privacy practices.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR PHI MAY BE USED AND DISCLOSED WITHOUT YOUR AUTHORIZATION:

To Provide Treatment.  The Agency may use your PHI to coordinate care within the agency and with others involved in your care, such as your attending physician, members of the Agency interdisciplinary team and other health care professionals who have agreed to assist the Agency in coordinating care.  For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.  The Agency also may disclose your PHI to individuals outside of the Agency involved in your care including pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment.  The Agency may include your PHI in invoices to collect payment from third parties for the care you receive from the Agency.  For example, the Agency may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Agency.  The Agency also may need to obtain prior approval from your insurer and may need to explain to the insurer your needs for care and the services that will be provided to you.

To Conduct Health Care Operations.  The Agency may use and disclose PHI for its own operations in order to facilitate the function of the Agency and as necessary to provide quality care to all of the patients.  Health care operations include such activities as:

• Quality assessment and improvement activities.
• Activities designed to improve health or reduce health care costs.
• Protocol development, case management and care coordination.
• Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
• Professional review and performance evaluation.
• Training programs including those in which students, trainees or practitioners in health care learn under supervision.
• Training of non-health care professionals.
• Accreditation, certification, licensing or credentialing activities.
• Review and auditing, including compliance reviews, medical reviews, legal services and                compliance programs.
• Business planning and development including cost management and planning related analyses and formulary development.
• Business management and general administrative activities of the Hospice.

For example the Agency may use your PHI to evaluate its staff performance, combine your PHI with other patients in evaluating how to more effectively serve all patients, disclose your health information to staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding a visit to you.  We may disclose your PHI to other health care providers for their health care operations if they have or had a relationship with you.

To Business Associates. We may use or disclose your PHI to an outside person or company that assists us in our operations.  They perform various services for us.  This includes, but is not limited to, auditing, accreditation, billing, legal services, and consulting services.  These outside companies are called “business associates” and they contract with us to keep any PHI received from us confidential in the same way we do.  These companies may create or receive medical information on our behalf.

To Family Members and Friends; Disaster Relief; Deceased Individuals.  We may disclose PHI about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care.  If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your PHI is in your best interest under the circumstances.  We may disclose your PHI to a family member, relative, or another person who was involved in the health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to the Agency.  But you also have the right to request a restriction on our disclosure of your medical information to someone who is involved in your care.

For Fundraising Activities.  The Agency may use certain PHI including your name, address, phone number, the dates you received care, the department from which you received service, your treating physician, outcome information, and health insurance status in order to contact you to raise money for the Agency.  The Agency may also release this information to a related foundation.  If you do not want the Agency to contact you for our fundraising and you wish to opt out of these contacts, or if you wish to opt back in to these contacts, you must notify the Chief Executive Officer at 800-417-7535 and indicate that you do not wish to be contacted.

For Appointment Reminders.  The Agency may use and disclose your PHI to contact you as reminder that you have an appointment for a home visit.

For Treatment Alternatives.  The Agency may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

When Legally Required or Permitted.  The Agency may use or disclose your PHI when it is required or permitted to do so by any Federal, State or local law.

When There Are Risks to Public Health.  The Agency may disclose your health information for public activities and purposes in order to:

• 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.
• 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.
• Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To Report Abuse, Neglect Or Domestic Violence.  We may disclose your PHI to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence if we have a reasonable belief that you may be a victim of abuse, neglect or domestic violence. If (i) you agree to the disclosure, (ii) the disclosure is required by law, or (iii) you are unable to agree because of incapacity and a law enforcement or other public official authorized to receive the report represents that the PHI for which disclosure is sought is not intended to be used against you and that an immediate enforcement activity that depends on the disclosure would be materially and adversely affected by waiting until you are able to agree to the disclosure.  In any of these situations, we will promptly inform you or your personal representative, if applicable, that such a disclosure has been or will be made unless we reasonably believe that notifying you would place you at risk of serious harm or if the personal representative to whom the disclosure would be made is reasonably believed by us to be responsible for the abuse, neglect, or injury and that informing such person would not be in your best interests.

To Conduct Health Oversight Activities.  We may use or disclose your PHI to let health oversight agencies make sure that we are following applicable laws.  For example, these health oversight activities may include audits, investigations, inspections, licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and government agencies that ensure compliance with civil rights laws.

In Connection With Judicial And Administrative Proceedings.  The Agency may disclose your PHI 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, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes.  As permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes as follows: • 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.
• For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
• Under certain limited circumstances, when you are the victim of a crime.
• To a law enforcement official if the Agency has a suspicion that your death was the result of criminal conduct including criminal conduct at the agency.
• In an emergency in order to report a crime.

To Coroners And Medical Examiners.  The Agency may disclose your PHI to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors.  The Agency may disclose your PHI 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, the agency may disclose your PHI prior to and in reasonable anticipation of your death.

For Organ, Eye Or Tissue Donation.  The Agency may use or disclose your PHI to organ procurement organization or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes.  The Agency may under very select circumstances, use your PHI for research, such as studying the effectiveness of a treatment you received.  Before the Agency discloses any of your PHI for such research purposes, the project will be subject to an extensive approval process.

In the Event of A Serious Threat To Health Or Safety.  The Agency may, consistent with applicable law and ethical standards of conduct, disclose your PHI if the Agency, 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.

For Specified Government Functions.  In certain circumstances, Federal regulations authorize the Agency to use or disclose your PHI to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation.  The Agency may release your PHI for worker’s compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE PHI

The following uses and disclosures will be made only with your authorization: (1) most uses and disclosures of psychotherapy notes, (2) uses and disclosures of your PHI for marketing purposes, (3) uses and disclosures that constitute the sale of PHI, and (4) other uses and disclosures not described in this Notice.  If you provide us with an authorization, you may withdraw the authorization in writing.  Any withdrawal will be effective for future uses and disclosures of your PHI, but it will not be effective for PHI that we have used or disclosed in reliance on the authorization.

In addition, we follow federal and state laws that require special privacy protections when we use or share highly confidential medical information.  For instance, medical information about communicable diseases and HIV/AIDS, and evaluation and treatment for a serious mental illness or substance abuse, is treated differently than other types of medical information.  We are required to obtain an authorization before using or disclosing highly confidential medical information in many circumstances.

If we receive or maintain any information about you from a substance use disorder treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you provide to the Part 2 Program to use and disclose its records for purposes of treatment, payment, or health care operations, we may use and disclose those records for treatment, payment, or health care operations as described in this Notice. If we receive or maintain Part 2 Program records through a specific consent you provide to us or another third party, we will use and disclose those records only as expressly permitted by that consent.

In no event will we use or disclose Part 2 Program records, or testimony describing information contained in those records, in any civil, criminal, administrative, or legislative proceedings brought by any federal, state, or local authority against you, unless authorized by your consent or by a court order issued after notice to you.

YOUR RIGHTS WITH RESPECT TO YOUR PHI

You have the following rights regarding your PHI that the Agency maintains:

Right to Request Restrictions.  You have the right to request certain restrictions of our use or disclosure of your PHI.  For example, you could restrict a specified nurse from use of your information, or request that we not disclose information to your spouse about a surgery you had.  We are not required to agree to your request in most cases.  But if we agree to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment.  We are required to agree to your request to restrict disclosure of your PHI to a health plan if the purpose of the disclosure is to carry out payment or health care operations and the PHI pertains solely to the service for which you, or a person other than the health plan, has paid us for in full.  For example, if you pay for a service completely out of pocket and ask us not to tell your insurance company about it, we will abide by this request.  A request for restriction must be in writing to our VP Clinical Services or the Chief Executive Officer.  We reserve the right to terminate any previously agreed-to restrictions (other than a restriction we are required to agree to by law).  We will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to PHI created after we inform you of the termination.  You may request restrictions on certain uses and disclosures of your health information.

Right to Receive Confidential Communications.  You have the right to request that the Agency communicate with you in a certain way or send information to you at a different address or contact you in a different way.  For example, you may ask that the Agency only conduct communications pertaining to your PHI with you privately with no other family members present.  If you wish to receive confidential communications, please contact our Chief Executive Officer at 1-800-417-7535.  The Agency will not request 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 your PHI, including billing records.  A request to inspect and copy records containing your PHI may be made to Chief Executive Officer at 1-800-417-7535.  If you request a copy of your PHI, the Agency may charge a reasonable fee for copying and assembling costs associated with your request.  In some cases, we may not let you see or copy your record.  If that happens, we will tell you why and explain to you your right to have the denial reviewed.  You also have the right to ask for a summary of this information.  If you request a summary, we may charge you a nominal fee.  You also have the right to request access to your PHI in electronic form, if it is readily producible in such form.  We may charge you a nominal fee if you request an electronic copy be provided on portable media.

Right to Amend.  You or your representative have the right to request that the Agency amend your records, if you believe that your PHI is incorrect or incomplete.  That request may be made as long as the information is maintained by the Agency.  A request for an amendment of records must be made in writing to Chief Executive Officer at Hospice of Darke County, Inc., 1350 N. Broadway St., Greenville, Ohio 45331.  The Agency may deny the request if it is not in writing or does not include a reason for the amendment.  The request also may be denied if your health information records were not created by the Agency, if the records you are requesting are not part of the Agency’s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion the Agency, the records containing your health information are accurate and complete.

Right to an Accounting.  You or your representative have the right to request an accounting of disclosures of your PHI made by the Agency for certain reasons, including reasons related to public purposes authorized by law and certain research.  The request for an accounting must be made in writing to Chief Executive Officer  of Hospice of Darke County, Inc., 1350 N. Broadway St., Greenville, Ohio 45331.  The request should specify the time period for the accounting. Accounting requests may not be made for periods of time in excess of the past six (6) years.  The Agency will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable costbased fee.

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) discovers a breach of your unsecured PHI.

Right to a Paper Copy of this Notice.  You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously.  If you agree to receive electronic notices by email, then you may receive an electronic copy of this Notice by email upon request.  Even if you have agreed to receive an electronic Notice, you may still request a paper copy.  To obtain a separate paper copy, please contact the Chief Executive Officer at 1-800-417-7535.

DUTIES OF THE AGENCY

The Agency is required by law to maintain the privacy of your PHI and to provide to you and your representative this Notice of its duties and privacy practices.  The Agency is required to abide by the terms of this Notice as may be amended from time to time.  The Agency reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI that it maintains.  If the Agency changes its Notice, the Agency will post the revised Notice where you will be able to read it, and provide you with a copy at your request.

COMPLAINTS.  You or your personal representative have the right to express complaints to the Agency and to the Secretary of the Department of Health and Human Services if you or your representative believe that your privacy rights have been violated.  Any complaints to the Agency should be made in writing to Chief Executive Officer, 1350 N. Broadway St., Greenville, Ohio 45331.  The Agency encourages you to express any concerns you may have regarding the privacy of your PHI.  You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

The Agency has designated the Chief Executive Officer as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards.  You may contact this person at 1350 N. Broadway St., Greenville, Ohio 45331, 1-800-417-7535.

EFFECTIVE DATE

This Notice is effective February 16^th, 2026.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:

Kristi Strawser, Chief Executive Officer, 1350 N. Broadway St., Greenville, Ohio 45331, 1-800-417-7535