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 how Assurance Hospice, Inc. and its employees, staff, volunteers, students and personnel may use or disclose your protected health information.
To obtain further information about matters covered in this notice or if you have any questions about this notice, please contact our Administrator at:
Assurance Hospice, Inc.
40 N. Altadena Drive, Suite 102
Pasadena, CA 91107
Phone: (626)793-3324
As a hospice patient, you have the right to be fully informed of your rights and responsibilities before the initiation of service. If or when a patient has been judged incompetent or at the patient’s request, the patient’s legal surrogate decision maker may exercise these rights as described below. Assurance Hospice will protect and promote your right to exercise these rights; you will not be subjected to discrimination or reprisal for exercising these rights.
Patient Rights
· To know Assurance Hospice’s mission and care and services provided directly or through contractual arrangement.
· The right to pain management and symptom control for conditions related to your terminal illness.
· To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse of any kind, including injuries of unknown source, and misappropriation of patient property. Corporal punishment is strictly prohibited.
· To be assured the personnel who provide care are qualified through education and experience to carry out the services for which they are responsible and to choose your attending physician.
· To be advised of what services are to be rendered and by what discipline (e.g. Registered Nurse, Chaplain, Social Worker, etc.) and the names and professional relationship of the staff who will see you.
· To exercise these rights and receive services appropriate to your needs and to expect Assurance Hospice to provide safe, professional care at the level of intensity needed, without unlawful restriction by reason of age, sex, race, creed, color, national origin, religion, economic status, educational background, ancestry, sexual orientation or marital status, source of payment for care or disability.
· To know the hours of care and service and how to obtain care or service after hours.
· To be fully informed by a physician of your medical condition, unless medically contraindicated. This includes information about your illness, the course of treatment and prognosis in terms you can understand.
· To participate in the planning of your medical treatment including pain and symptom management as well as to be involved in resolving dilemmas about your care, treatment and services. This includes the right to refuse treatment and services to the extent permitted by law and to be informed of the expected consequences of such refusal.
· To allow your family and other individuals to be involved in care, treatment and service decisions to the extent you desire and as allowed by law.
· To receive reasonable continuity of care, to know in advance the time and location of visits, and to receive reasonable responses to any reasonable request made for service.
· To be involved in the initial and ongoing development and implementation of your plan of care.
· To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. Case discussion, consultation, examination and treatment are confidential and will be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual.
· To have your cultural, psychosocial, spiritual and personal values, beliefs, and preferences respected.
· To receive considerate and respectful care and to have your property treated with respect.
· To have staff communicate in a language or form you can reasonably be expected to understand.
· To be assured of confidential treatment of personal and clinical records, to have access to and approve or refuse their release to any individual outside the hospice, except in the case of transfer to another health facility, or as required by law, or third-party payment contract. For a complete list of your rights under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule please read Assurance Hospice’s Notice of Privacy Practices.
· To be fully informed of services available through Assurance Hospice, limitations on these services and of related charges, including any charges for services not covered under Title XVIII or XIX of the Social Security Act.
· To know the cost of services that will be billed to you (verbally and in writing).
· To be advised, in advance, of any change in treatment.
· To formulate an advanced directive and to receive a copy of our policy and procedure regarding Advanced Directives, and be informed of Assurance Hospice’s policy on withholding resuscitative services and the withdrawal of life sustaining treatment.
· The California Laws regarding Advanced Directives are CA Probate Code: Section 4670-4678, and more information regarding the elaboration of Advanced Directives can be found at the California Attorney General’s website: http://oag.ca.gov/consumers/general/adv_hc_dir[LS1]
· To refuse to participate in research, investigational or experimental studies or clinical trials without compromise to your access to care, treatment or services.
· To be informed of what to do in an emergency.
· To terminate hospice services even against the advice of physicians. To revoke hospice, the patient must sign and file a revocation statement with Assurance Hospice, which may be obtained from Assurance Hospice. If the patient revokes the hospice benefit, they still have subsequent election periods left for future use.
· To receive hospice care from a different provider, which the patient can transfer once every election period. This transfer is not a revocation of the hospice benefit. To transfer, the patient or the patient’s representative must first confirm that the hospice to which they wish to be admitted can admit them and on what date. The patient must file, with Assurance Hospice and the new hospice, a statement that includes the names of both Hospices, and the date that the change is to be effective. No benefits will be lost by properly transferring to another hospice program.
· To voice complaints/grievances about treatment or care that is (or fails to be) furnished, or regarding lack of respect for property by anyone who is furnishing services on behalf of Assurance Hospice, without retaliation or discrimination for same and to be informed of the procedure to voice complaints/grievances with Assurance Hospice. Complaints or questions may be registered with Assurance Hospice by phone, in person, or in writing Monday – Friday 8:00 a.m. – 5:30 p.m.
Assurance Hospice
40 N. Altadena Drive Suite 102
Pasadena, CA 91107
(626)793-3374
· To be informed of the State Hotline. The California Department of Public Health has a hotline for complaints or questions about Advanced Directives or local hospice organizations. The number is (800) 228-1019. The California Department of Public Health is located at 5555 Ferguson Drive, Third Floor, Commerce, CA 90022. Complaints may be registered confidentially and without retaliation or discrimination in any manner for such complaint or question.
· To complain about our hospice to the Joint Commission 24 hours a day, seven days a week at (800) 994-6610.
Patient Responsibilities
· To be treated exclusively by Assurance Hospice for as long as Assurance Hospice is the elected care provider. The patient waives services from another provider without first revoking the hospice benefit. The patient also waives any services that are for the treatment of the terminal condition or a related condition except for those provided by Assurance Hospice or its representatives or designees.
· To provide, to the best of your knowledge, complete and accurate information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
· To report perceived risks in your care and unexpected changes in your condition.
· To provide feedback regarding hospice services, your needs and expectations, and ask questions regarding care or services.
· To inform Assurance Hospice when you will not be able to keep your hospice appointments.
· To treat Assurance Hospice staff and property with consideration and respect.
· To follow directions and Assurance Hospice’s policies and procedures concerning patient care and conduct.
· To sign the required consents and release for insurance billing and provide insurance and financial records as requested and to promptly meet any financial obligation agreed to with Assurance Hospice.
· To inform Assurance Hospice of any problems or dissatisfaction with patient care.
· To notify Assurance Hospice of any changes in address, telephone number, or insurance/payment information.
· To remain under a doctor’s care while receiving hospice services.
· To inform Assurance Hospice of any advance directives or any changes in advance directives and to provide Assurance Hospice with a copy.
· To cooperate with your primary doctor, hospice staff and other caregivers.
· To obtain medications, supplies and equipment ordered by the patient’s physician, if they cannot be obtained or supplied by Assurance Hospice.
· To accept the consequences of any refusal of treatment or choice of non-compliance with the care plan.
· To have adequate resources/plans to provide for up to twenty-four (24)-hour care in the home should your condition warrant it.
· To provide a safe environment in which care can be given. In the event that conduct occurs such that the patient’s or staff’s welfare or safety is threatened, services may be terminated.
· To inform Assurance Hospice of any intent to transfer Hospice Care to another hospice provider by filing with both Assurance Hospice and the new hospice provider a statement that includes the names of both hospices, and the date that the change is to be effective; that by transferring properly, no benefits will be lost.
· In the event that a transfer to another hospice is desired, to confirm that the new hospice provider is able to admit the patient, and on what date.
· To inform Assurance Hospice of any desire to discontinue hospice services, in advance of taking such action, in writing, by signing and filing revocation form which can be obtained from Assurance Hospice.
The patient may be discharged for any of the following reasons:
· The patient moves out of Assurance Hospice’s service area or transfers to another hospice.
· Assurance Hospice determines that the patient is no longer terminally ill.
· Assurance Hospice determines that the patient’s (or other persons in the patients’ home) behavior is disruptive, abusive, or uncooperative to the extent that the delivery of care or the ability of the hospice to operate effectively is seriously impaired.
· Upon discharge for these reasons, the patient is no longer covered for hospice care, but resume coverage of the benefits waived upon acceptance of hospice care, and may elect to receive hospice care again if eligible to receive the benefit.
· In the event that the hospice benefit is terminated by Assurance Hospice, the patient will be informed within a reasonable amount of time.
This notice describes how Assurance Hospice, Inc. and its employees, staff, volunteers, students and personnel may use or disclose your protected health information.
To obtain further information about matters covered in this notice or if you have any questions about this notice, please contact our Administrator at:
Assurance Hospice, Inc.
40 N. Altadena Drive, Suite 102
Pasadena, CA 91107
Phone: (626)793-3324
As a hospice patient, you have the right to be fully informed of your rights and responsibilities before the initiation of service. If or when a patient has been judged incompetent or at the patient’s request, the patient’s legal surrogate decision maker may exercise these rights as described below. Assurance Hospice will protect and promote your right to exercise these rights; you will not be subjected to discrimination or reprisal for exercising these rights.
Patient Rights
· To know Assurance Hospice’s mission and care and services provided directly or through contractual arrangement.
· The right to pain management and symptom control for conditions related to your terminal illness.
· To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse of any kind, including injuries of unknown source, and misappropriation of patient property. Corporal punishment is strictly prohibited.
· To be assured the personnel who provide care are qualified through education and experience to carry out the services for which they are responsible and to choose your attending physician.
· To be advised of what services are to be rendered and by what discipline (e.g. Registered Nurse, Chaplain, Social Worker, etc.) and the names and professional relationship of the staff who will see you.
· To exercise these rights and receive services appropriate to your needs and to expect Assurance Hospice to provide safe, professional care at the level of intensity needed, without unlawful restriction by reason of age, sex, race, creed, color, national origin, religion, economic status, educational background, ancestry, sexual orientation or marital status, source of payment for care or disability.
· To know the hours of care and service and how to obtain care or service after hours.
· To be fully informed by a physician of your medical condition, unless medically contraindicated. This includes information about your illness, the course of treatment and prognosis in terms you can understand.
· To participate in the planning of your medical treatment including pain and symptom management as well as to be involved in resolving dilemmas about your care, treatment and services. This includes the right to refuse treatment and services to the extent permitted by law and to be informed of the expected consequences of such refusal.
· To allow your family and other individuals to be involved in care, treatment and service decisions to the extent you desire and as allowed by law.
· To receive reasonable continuity of care, to know in advance the time and location of visits, and to receive reasonable responses to any reasonable request made for service.
· To be involved in the initial and ongoing development and implementation of your plan of care.
· To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. Case discussion, consultation, examination and treatment are confidential and will be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual.
· To have your cultural, psychosocial, spiritual and personal values, beliefs, and preferences respected.
· To receive considerate and respectful care and to have your property treated with respect.
· To have staff communicate in a language or form you can reasonably be expected to understand.
· To be assured of confidential treatment of personal and clinical records, to have access to and approve or refuse their release to any individual outside the hospice, except in the case of transfer to another health facility, or as required by law, or third-party payment contract. For a complete list of your rights under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule please read Assurance Hospice’s Notice of Privacy Practices.
· To be fully informed of services available through Assurance Hospice, limitations on these services and of related charges, including any charges for services not covered under Title XVIII or XIX of the Social Security Act.
· To know the cost of services that will be billed to you (verbally and in writing).
· To be advised, in advance, of any change in treatment.
· To formulate an advanced directive and to receive a copy of our policy and procedure regarding Advanced Directives, and be informed of Assurance Hospice’s policy on withholding resuscitative services and the withdrawal of life sustaining treatment.
· The California Laws regarding Advanced Directives are CA Probate Code: Section 4670-4678, and more information regarding the elaboration of Advanced Directives can be found at the California Attorney General’s website: http://oag.ca.gov/consumers/general/adv_hc_dir[LS1]
· To refuse to participate in research, investigational or experimental studies or clinical trials without compromise to your access to care, treatment or services.
· To be informed of what to do in an emergency.
· To terminate hospice services even against the advice of physicians. To revoke hospice, the patient must sign and file a revocation statement with Assurance Hospice, which may be obtained from Assurance Hospice. If the patient revokes the hospice benefit, they still have subsequent election periods left for future use.
· To receive hospice care from a different provider, which the patient can transfer once every election period. This transfer is not a revocation of the hospice benefit. To transfer, the patient or the patient’s representative must first confirm that the hospice to which they wish to be admitted can admit them and on what date. The patient must file, with Assurance Hospice and the new hospice, a statement that includes the names of both Hospices, and the date that the change is to be effective. No benefits will be lost by properly transferring to another hospice program.
· To voice complaints/grievances about treatment or care that is (or fails to be) furnished, or regarding lack of respect for property by anyone who is furnishing services on behalf of Assurance Hospice, without retaliation or discrimination for same and to be informed of the procedure to voice complaints/grievances with Assurance Hospice. Complaints or questions may be registered with Assurance Hospice by phone, in person, or in writing Monday – Friday 8:00 a.m. – 5:30 p.m.
Assurance Hospice
40 N. Altadena Drive Suite 102
Pasadena, CA 91107
(626)793-3374
· To be informed of the State Hotline. The California Department of Public Health has a hotline for complaints or questions about Advanced Directives or local hospice organizations. The number is (800) 228-1019. The California Department of Public Health is located at 5555 Ferguson Drive, Third Floor, Commerce, CA 90022. Complaints may be registered confidentially and without retaliation or discrimination in any manner for such complaint or question.
· To complain about our hospice to the Joint Commission 24 hours a day, seven days a week at (800) 994-6610.
Patient Responsibilities
· To be treated exclusively by Assurance Hospice for as long as Assurance Hospice is the elected care provider. The patient waives services from another provider without first revoking the hospice benefit. The patient also waives any services that are for the treatment of the terminal condition or a related condition except for those provided by Assurance Hospice or its representatives or designees.
· To provide, to the best of your knowledge, complete and accurate information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
· To report perceived risks in your care and unexpected changes in your condition.
· To provide feedback regarding hospice services, your needs and expectations, and ask questions regarding care or services.
· To inform Assurance Hospice when you will not be able to keep your hospice appointments.
· To treat Assurance Hospice staff and property with consideration and respect.
· To follow directions and Assurance Hospice’s policies and procedures concerning patient care and conduct.
· To sign the required consents and release for insurance billing and provide insurance and financial records as requested and to promptly meet any financial obligation agreed to with Assurance Hospice.
· To inform Assurance Hospice of any problems or dissatisfaction with patient care.
· To notify Assurance Hospice of any changes in address, telephone number, or insurance/payment information.
· To remain under a doctor’s care while receiving hospice services.
· To inform Assurance Hospice of any advance directives or any changes in advance directives and to provide Assurance Hospice with a copy.
· To cooperate with your primary doctor, hospice staff and other caregivers.
· To obtain medications, supplies and equipment ordered by the patient’s physician, if they cannot be obtained or supplied by Assurance Hospice.
· To accept the consequences of any refusal of treatment or choice of non-compliance with the care plan.
· To have adequate resources/plans to provide for up to twenty-four (24)-hour care in the home should your condition warrant it.
· To provide a safe environment in which care can be given. In the event that conduct occurs such that the patient’s or staff’s welfare or safety is threatened, services may be terminated.
· To inform Assurance Hospice of any intent to transfer Hospice Care to another hospice provider by filing with both Assurance Hospice and the new hospice provider a statement that includes the names of both hospices, and the date that the change is to be effective; that by transferring properly, no benefits will be lost.
· In the event that a transfer to another hospice is desired, to confirm that the new hospice provider is able to admit the patient, and on what date.
· To inform Assurance Hospice of any desire to discontinue hospice services, in advance of taking such action, in writing, by signing and filing revocation form which can be obtained from Assurance Hospice.
The patient may be discharged for any of the following reasons:
· The patient moves out of Assurance Hospice’s service area or transfers to another hospice.
· Assurance Hospice determines that the patient is no longer terminally ill.
· Assurance Hospice determines that the patient’s (or other persons in the patients’ home) behavior is disruptive, abusive, or uncooperative to the extent that the delivery of care or the ability of the hospice to operate effectively is seriously impaired.
· Upon discharge for these reasons, the patient is no longer covered for hospice care, but resume coverage of the benefits waived upon acceptance of hospice care, and may elect to receive hospice care again if eligible to receive the benefit.
· In the event that the hospice benefit is terminated by Assurance Hospice, the patient will be informed within a reasonable amount of time.