Making a Difference in Home Health by s981nv

VIEWS: 6 PAGES: 22

									       Magnolia Home Health Care Services, Inc.
         178 S. Victory Blvd. Suite 207, Burbank, CA 91502
              Tel: 818-566-4411 Fax: 818-566-4404




    Making a Difference in Home Health




              Welcome to
Magnolia Home Health Care Services, Inc.
                            Magnolia Home Health Care Services, Inc.
                                178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                     Tel: 818-566-4411 Fax: 818-566-4404




Dear Client,


I am pleased to welcome you to Magnolia Home Health Care Services, Inc. family. Here, you will discover the joy of a hassle-
free medical visit. Because our greatest goal is to guarantee your satisfaction, our finely trained personnel will be working 24
hours a day to fulfill your needs and to provide you with the finest quality of health care.


Magnolia Home Health Care Services, Inc. delivers leading-edge knowledge. Through our personalized visits and regular
appointments, you will encounter respected personnel, working hard to meet your needs. These are people who enjoy
helping you and who make themselves accessible to devoting long hours for your benefit.


With a rich diversity of ethnicities and nationalities, staff is central to what makes Magnolia Home Health Care Services, Inc.
an unsurpassed environment of friendliness and mutual respect. Furthermore, we accommodate to the multi-cultural nature of
the Los Angeles area by providing staff fluent in variety of languages.


In addition, as an equal opportunity partner, Magnolia Home Health Care Services, Inc. does not discriminate against any
person on the basis of race, color, creed, religion, sex, sexual preferences, national origin, disability, or age in admission,
treatment, staffing or participation in its program, services, and employment.




Sincerely,


Armenuhi, Amy Keshishyan
President
Magnolia Home Health Care Services, Inc.
                    Magnolia Home Health Care Services, Inc.
                        178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                             Tel: 818-566-4411 Fax: 818-566-4404



      SUGGESTIONS, QUESTIONS, COMPLAINTS AND GRIEVANCES

               We at Magnolia Home Health Care Services, Inc. would like to hear from you.
                It is our Agency’s commitment to ensure your finest home care experience.
           For suggestions, questions, complaints or grievances, you can call or write directly to:


                                       Armenuhi, Amy Keshishyan
                           178 S. Victory Blvd. Suite 207, Burbank, CA 91201
                                            Tel: (818) 566-4411



                               YOU MAY ALSO CALL MEDICARE
                                         HOTLINE NUMBER
                                             1-800-228-1019
                                           24 HOURS A DAY


                                                    OR


                                        JOINT COMMISSION
                         (for any concerns about your care and/or safety)
                                         HOTILINE NUMBER
                                             1-800-994-6610
                                         complaint@jcaho.org




The purpose of this Hotline Number is to receive your concern regarding recipient abuse, neglect and
                     non-compliance with the Advance Directives requirement.
   This number could also be used to obtain information regarding local Home Health Agencies.
         Magnolia Home Health Care Services, Inc.
           178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                Tel: 818-566-4411 Fax: 818-566-4404




Financial Information
                       Magnolia Home Health Care Services, Inc.
                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                               Tel: 818-566-4411 Fax: 818-566-4404



                                    Schedule of Charges - Private Pay
Skilled Nursing
_______________________________
    Initial Evaluation $140.00
      Follow up Visit         $140.00

Home Health Aide
_______________________________
    Visit              $100.00


Physical Therapy
_______________________________
    Initial Evaluation $150.00
    Follow up Visit    $150.00

Speech Therapy
_______________________________
    Initial Evaluation $150.00
    Follow up Visit    $150.00

Medical Social Services
_______________________________
    Visit              $175.00




Note:
________________________________________________________
    Magnolia Home Health Care Services, Inc. will bill Medicare, Medical or any other insurance company that
      the patient has.

Charges that the patient may have to pay:
______________________________________________________________
    Nothing for services that is medically necessary
    20% of approved amount for durable medical equipment
                                                  Magnolia Home Health Care Services, Inc.
                                                       178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                                            Tel: 818-566-4411 Fax: 818-566-4404


                                                                                Medicare Part A

                               Services                                                 Benefit                         Medicare Pays                              You Pay 1
Hospitalization                                                                       First 60 days                         All but $812                             $812
Semi-private room, meals, General nursing and other                                  61 st to 90th day                   All but $203 a day                        $203 a day
hospital services and supplies (includes care in critical
                                                                                    91 st to 1 50th day2                 All but $406 a day                        $406 a day
access hospitals and inpatient mental health care). This
does not include private duty nursing, or a TV or telephone                         Beyond 150 days                            Nothing                              All costs
in your room, unless medically necessary.
Skilled Nursing Facility Care                                                         First 20 days                 100% of approved amount                         Nothing
Semi-private room, meals, skilled nursing and rehabilitative
                                                                                   Additional 80 days                  All but $10 1.50 a day                 Up to $101.50 a day
services and other services and supplies (after a related 3-

day hospital stay).                                                                 Beyond 100 days                            Nothing                              All costs

Home Health Care                                                              Unlimited as long as              100% of approved amount;                  Nothing for services;
Part-time skilled nursing care, physical therapy,                             you meet Medicare                 80% of approved amount for                 20% of approved amount
occupational therapy, speech-language therapy, home                           conditions.                       durable medical equipment.                for durable medical
health aide services, durable medical equipment                                                                                                           equipment.
(wheelchairs, hospital beds, oxygen and walkers) and
medical supplies and other services. or intermittent skilled
care, home health aide
Hospice Care                                                                  F or as long as doctor            All but limited costs for                 Co-payment of up to $5
Medical and support services from a Medicare-approved                         certifies need.                   outpatient drug and inpatient             for outpatient
hospice for people with a terminal illness, drugs for                                                           respite care.                             prescription drugs and
symptom control and pain relief, and other services not                                                                                                   5% of approved amount
otherwise covered by Medicare. Short-term hospital and                                                                                                     for inpatient respite care;
inpatient respite care are covered when needed, however                                                                                                   room and board for
room and board are not covered.                                                                                                                           inpatient hospice care.
Blood                                                                         Unlimited if medically            All but first 3 pints per                 For first 3 pints. 3
      When furnished by a hospital or skilled nursing facility
                                                                              necessary.                        calendar year.
      during a covered stay.
For more information regarding Medicare Part A Benefits, you can call the Social Security Administration at 1-800-722-1213 or your local Social Security office.


           1.   Either you or your insurance company is responsible for paying the amounts listed in the "You Pay" column.
           2.   This 60-reserve-days benefit may be used only once in a lifetime (see p.7).
           3.   Blood paid for or replaced under Part B of Medicare during the calendar year does not have to be paid for or replaced under Part A.
                                                  Magnolia Home Health Care Services, Inc.
                                                       178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                                            Tel: 818-566-4411 Fax: 818-566-4404


                                                                                 Medicare Part B

                             Services                                               Benefit                        Medicare Pays                                You Pay 1
   Medical Expenses                                                      Unlimited if medically              80% of approved amount                 $100 deductible, plus 20% of
   Doctor's services (not routine physical exams),                       necessary.                          (after $100 deductible).               approved amount after
   outpatient medical and surgical services and                                                              Reduced to 50% for most                deductible, plus 20% for all
   supplies, diagnostic tests, ambulatory surgery center                                                     outpatient mental health               outpatient physical,
   facility fees for approved procedures, and durable                                                        services.                              occupational and speech-
   medical equipment. This also covers second surgical                                                                                              language therapy services.
   opinions, outpatient mental health care and
   outpatient physical and occupational therapy,
   including speech-language therapy.
   Clinical Laboratory Services                                          Unlimited if medically              Generally 100% of                      Nothing for services.
   Blood tests, urinalyses and more.                                     necessary.                          approved amount.
   Home Health Care                                                      Unlimited as long as you            100% of approved amount;               Nothing for services; 20% of
   Part-time skilled nursing care, physical therapy,                     meet Medicare                       80% of approved amount                 approved amount for durable
   occupational therapy, speech-language therapy,                        conditions.                         for durable medical                    medical equipment.
   home health aide services, medical social services,                                                       equipment.
   durable medical equipment and medical supplies,
   and other services
   Outpatient Hospital Treatment                                         Unlimited if medically              Medicare payment to                    Coinsurance or co-payment
   Hospital services and supplies received as an                         necessary.                          hospital based on hospital             amount (may vary according to
   outpatient as part of a doctor's care.                                                                    cost.                                  service).
   Blood                                                                                                     80% of approved amount                 First 3 pints plus 20% of
   Pints of blood you get as an outpatient or as part of a               Unlimited if medically              (after $100 deductible and             approved amount for additional
   Part B covered service.                                               necessary.                          starting with 4th pint).               pints (after $100 deductible)?

   For more information regarding Medicare 'part B Benefits, you can call the Social Security Administration at 1-800-722-1213 or your local Social Security office.


1. Either you or your insurance company are responsible for paying the amounts listed in the "You Pay" column.
2. Blood paid for or replaced under Part A of Medicare during the calendar year does not have to be paid for or replaced under Part B.
   Magnolia Home Health Care Services, Inc.
     178 S. Victory Blvd. Suite 207, Burbank, CA 91502
          Tel: 818-566-4411 Fax: 818-566-4404




Privacy/Rights Information
                                    Magnolia Home Health Care Services, Inc.
                                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                               Tel: 818-566-4411 Fax: 818-566-4404




        THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974). THIS
        STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED TO RELEASE OR TO USE YOUR HEALTH CARE INFORMATION.

I. AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER, AND WHETHER OR NOT
   YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THIS ASSESSMENT. Sections 1102(a), 1154, 1861(0), 1861(z), 1863, 1864, 1865,
   1866, 1871, 1891(b) of the Social Security Act.
Medicare and Medicaid participating home health agencies must do a complete assessment that accurately reflects your current health and includes information that can
be used to show your progress toward your health goals. The home health agency must use the Outcome and Assessment Informatio n Set] (OASIS) when evaluating
your health. To do this, the agency must get information from every patient. This information is used by the Health Care Financing Administration (HCFA, t he federal
Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate health care to its patients. You have the right to
refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the federal Privacy Act
of 1974 and the "Home Health Agency Outcome and Assessment Information Set I (HHA OASIS) System of Records. You have the right to see, copy, review, and
request correction of your information in the HHA OASIS System of Records.

II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED
The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-70-9002. Your health
care information in the HHA OASIS System of Records will be used for the following purposes:
 A support litigation involving the Health Care Financing Administration;
 A support regulatory, reimbursement, and policy functions performed within the Health Care Financing Administration or by a c ontractor or consultant; A
 study the effectiveness and quality of care provided by those home health agencies;
 A survey and certification of Medicare and Medicaid home health agencies;
 A provide for development, validation, and refinement of a Medicare prospective payment system;
 A enable regulators to provide home health agencies with data for their internal quality improvement activities;
A support research, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restor ation or maintenance of health, and for
    health care payment related projects; and
 A support constituent requests made to a Congressional representative.
III. ROUTINE USES
These "routine uses] specify the circumstances when the Health Care Financing Administration may release your information fro m the HHA OASIS System of
Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of
the information may be to:
       1. the federal Department of Justice for litigation involving the Health Care Financing Administration;
       2.    contractors or consultants working for the Health Care Financing Administration to assist in the performance of a service rel ated to this system of
             records and who need to access these records to perform the activity;
       3. an agency of a State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of health care services
             provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of Federal/State home health agency
             programs within the State;
       4.    another Federal or State agency to contribute to the accuracy of the Health Care Financing Administration's health insurance operations (payment,
             treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs;
       5. Peer Review Organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health agency quality of care;
       6.    an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disa bility, the restoration or
             maintenance of health, or payment related projects;
       7. a congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained.
IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION
The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quali ty care. It is important that the
information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard t o be sure that the agency is giving you quality
services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services.
NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your
               representative to sign this statement to document that this statement was given to you. Your signature is NOT required. If yo u or your representative sign
               the statement, the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement.

                                                                     CONTACT INFORMATION
                   If you want to ask the Health Care Financing Administration to see, review, copy, or correct your personal health information that the
                                                     Federal agency maintains in its HHA OASIS System of Records:
                           Call1-800-MEDICARE, toll free, for assistance in contacting the HHA OASIS System Manager.
                                                TTY for the hearing and speech impaired: 1-877-486-2048.
                          Magnolia Home Health Care Services, Inc.
                              178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                   Tel: 818-566-4411 Fax: 818-566-4404



                                                 PATIENT RIGHTS
                                             ("HHA" stands for Home Health Agency)
Notice of Rights
(l)     The HHA must provide the patient with a written notice of the patient's
        rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation
        of treatment.
(2)     The HHA must maintain documentation showing that it has complied with the requirements of this
        section.

Exercise of Rights and Respect for Property and Person
(I)     The patient has the right to exercise his or her rights as a patient of the HHA.

Right to be Informed and to Participate in Planning Care and Treatment
( I)    The patient has the right to be informed, in advance, about the care to be furnished, and of any changes in
        the care to be furnished writing as soon as possible, but no later than 30 calendar days from the date that
        the HHA becomes aware of a change.
        a.        The HHA must advise the patient in advance of the disciplines that will furnish care, and the
                  frequency of visits proposed to be furnished.
        b.        The HHA must advise the patient in advance of any change in the plan of care before the change is
                  made.
(2)     The patient has the right to participate in the planning of the care.
        a.        The HHA must advise the patient in advance of the right to participate in planning the care or
                  treatment and in planning changes in the care or treatment.
        b.        The HHA complies with the requirements of Subpart I of part 489 of this chapter relating to
                  maintaining written policies and procedures regarding advance directives. The HHA must inform
                  and distribute written information to the patient, in advance, concerning its policies on advance
                  directives, including a description of applicable State law. The HHA may furnish advanced
                  directives information to a patient at the time of the first home visit, as long as the information is
                  furnished before care is provided.

Confidentiality of Medical Records
(l)    The patient has the right to confidentiality of the clinical records maintained by
        the HHA.
(2)    The HHA must advise the patient of the agency's policies and procedures regarding disclosure of
        clinical records.

Patient Liability for Payment
(I)     Before the care is initiated, the HHA must inform the patient, orally and in writing, of:
        a.       The extent to which payment may be expected from Medicare, Medicaid, or any other federally
                 funded or aided program known to the HHA;
        b.       The charges for services that will not be covered by Medicare; and
        c.       The charges that the individual may have to pay.
Home Health Hotline
(1)     The patient has the right to be advised of the availability of the toll-free HHA hotline in the State. When the agency
        accepts the patient for treatment or care, the HHA must advise the patient in writing of the telephone number of
        the home health hotline established by the State, the hours of its operation, and that the purpose of the hotline is to
        receive complaints or questions about local HHA's. The patient also has the right to use this hotline to lodge
        complaints concerning the implementation of the advanced directives requirements.
                      Magnolia Home Health Care Services, Inc.
                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                               Tel: 818-566-4411 Fax: 818-566-4404


                   NOTICE OF HOME CARE PRIVACY PRACTICES
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.

Magnolia Home Health Care Services, Inc. may use your health information, information that constitutes
protected health information as defined in the Privacy Rule of the Administrative Simplification provisions
of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you
treatment, obtaining payment for your care and conducting health care operations. The Agency has
established policies to guard against unnecessary disclosure of your health information.


       THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND

PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

        To Provide Treatment. The Agency may use your health information to coordinate care within the
Agency and with others involved in your care, such as your attending physician 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 health care information to individuals outside of the Agency involved in
your care including family members, pharmacists, suppliers of medical equipment or other health care
professionals.

        To Obtain Payment. The Agency may include your health information 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 need for home care and the services that will be provided to
you.

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

-Quality assessment and improvement activities.

-Activities designed to improve health or reduce health care costs.

-Protocols 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.

- Training programs including those in which students, trainees or practitioners in health care learn
under supervision.
                       Magnolia Home Health Care Services, Inc.
                           178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                Tel: 818-566-4411 Fax: 818-566-4404

-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 Agency.



       Fundraising for the benefit of the Agency.
       For example the Agency may use your health information to evaluate its staff performance,
       combine your health information with other Agency patients in evaluating how to more
       effectively serve all Agency patients, disclose your health information to Agency staff and
       contracted personnel for training purposes, use your health information to contact you as a
       reminder regarding a visit to you, or contact you as part of general fundraising and community
       information mailings (unless you tell us you do not want to be contacted).


        For Fundraisin2 Activities. The Agency may use information about you including your name,
address, phone number and the dates you received care in order to contact you to raise money for the
Agency. The Agency may also release this information to a related Agency foundation. If you do not want
the Agency to contact you, notify HIPAA Compliance Officer, 178 S. Victory Blvd., Burbank, CA 91502,
Tel: 818 566-4411 and indicate that you do not wish to be contacted.

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

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


THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES
FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED.


When Legally Required. The Agency will disclose your health information when it is required 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.
                      Magnolia Home Health Care Services, Inc.
                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                               Tel: 818-566-4411 Fax: 818-566-4404

        To Report Abuse, Neglect Or Domestic Violence. The Agency is allowed to notify government
authorities if the Agency believes a patient is the victim of abuse, neglect or domestic violence. The
Agency will make this disclosure only when specifically required or authorized by law or when the patient
agrees to the disclosure.

        To Conduct Health Oversight Activities. The Agency may disclose your health information to a
health oversight agency for activities including audits, civil administrative or criminal investigations,
inspections, licensure or disciplinary action. The Agency, however, may not disclose your health
information if you are the subject of an investigation and your health information is not directly related to
your receipt of health care or public benefits.

         In Connection With Judicial And Administrative Proceedings. The Agency may disclose
your health information 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 law enforcement official if the Agency has suspicion that your death was the result of criminal
conduct including criminal conduct at the Agency.


-In an emergency to report a crime.

        To Coroners And Medical Examiners. The Agency may disclose your health information
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 health information 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 health
information prior to and in reasonable anticipation of your death.
        For Organ, Eye Or Tissue Donation. The Agency may use or disclose your health information
to organ procurement organizations 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 health
information for research. Before the Agency discloses any of your health information for such
research purposes, the project will be subject to an extensive approval process.
                       Magnolia Home Health Care Services, Inc.
                           178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                Tel: 818-566-4411 Fax: 818-566-4404

        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 health information 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, the Federal regulations
authorize the Agency to use or disclose your health information 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 health information for worker's
compensation or similar programs.


AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION


                        Other than is stated above, the Agency will not disclose your health information
                        without your written authorization. If you or your representative authorize the
                        Agency to use or disclose your health information, you may revoke the
                        authorization in writing at any time thereafter.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION


You have the following rights regarding your health information that the Agency maintains:


-Right to request restrictions. You may request restrictions on certain uses and disclosures of
           your health information. You have the right to request a limit on the Agency's disclosure of
           your health information to someone who is involved in your care or the payment of your care.
           However, the Agency is not required to agree to your request. If you wish to make a request for
           restrictions, please contact: HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207,
           Burbank, CA 91502, Tel: 818-566-4411

-Right to receive confidential communications. You have the right to request that the Agency
            communicate with you in a certain way. For example, you may ask that the Agency only
            conduct communications pertaining to your health information with you privately with no other
            family members present. If you wish to receive confidential communications, please contact:
            HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207, Burbank, CA 91502, Tel: 818-566-
            4411. 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 health
            information, including billing records. A request to inspect and copy records containing your
            health information may be made to HIPAA Compliance Officer, 178 S. Victory Blvd. Suite
            207, Burbank, CA 91502, Tel: 818-566-4411. If you request a copy of your health
            information, the Agency may charge a reasonable fee for copying and assembling costs
            associated with your request.                             .•
                      Magnolia Home Health Care Services, Inc.
                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                               Tel: 818-566-4411 Fax: 818-566-4404

-Right to amend health care information. You or your representative have the right to request that the
           Agency amend your records, if you believe that your health information 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 HIPAA Compliance Officer,
           178 S. Victory Blvd. Suite 207, Burbank, CA 91502, Tel: 818-566-4411. 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 pat1 of the health information you or your representative are
           permitted to inspect and copy, or if, in the opinion of 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 health information 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
HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207, Burbank, CA 91502, Tel: 818-566-4411.



       The request should specify the time period for the accounting starting on or after January 1, 2008.
                  Accounting requests may not be made for periods of time in excess of six (6) years. The
                  Agency would 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.


       -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. To obtain a separate paper copy, please
                          contact: HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207,
                          Burbank, CA 91502, Tel: 818-566-4411.



DUTIES OF THE AGENCY


The Agency is required by law to maintain the privacy of your health information 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 health information that it
maintains. If the Agency changes its Notice, the Agency will provide a copy of the revised Notice to you or
your appointed representative. You or your personal representative has the right to express complaints to
the Agency and to the Secretary of DHHS if you or your representative believes that your privacy rights
have been violated. Any complaints to the Agency should be made in writing to HIPAA Compliance
Officer, 178 S. Victory Blvd. Suite 207, Burbank, CA 91502, Tel: 818-566-4411. The Agency encourages
you to express any concerns you may have regarding the privacy of your information. You will not be
retaliated against in any way for filing a complaint.
                    Magnolia Home Health Care Services, Inc.
                        178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                             Tel: 818-566-4411 Fax: 818-566-4404



CONTACT PERSON

The Agency has designated HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207, Burbank, CA
91502, Tel: 818-566-4411. as its contact person for all issues regarding patient privacy and your rights
under the Federal privacy standards. You may contact this person at the above address and phone
number.

EFFECTIVE DATE

This Notice is effective January 1, 2008.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
HIPAA Compliance Officer, 178 S. Victory Blvd. Suite 207, Burbank, CA 91502, Tel: 818-566-
4411.
                     Magnolia Home Health Care Services, Inc.
                         178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                              Tel: 818-566-4411 Fax: 818-566-4404



                                                                     CONFIDENTIALITY OF
                                                              INFORMATION Policy No. 1-015.1



PURPOSE




To assure that the patient's right to privacy is protected by following the policies and procedures
regarding confidentiality and use and disclosure of protected health information (PHI), as necessary.




POLICY




Agency and its personnel will maintain as confidential all patient-protected health information. Protected
health information will be used and disclosed in accordance with the organization's policies and
procedures. (See "Uses and Disclosures of PHI" Policy No. 5-015.)




PROCEDURE




1.    On the first day during the orientation process, this Confidentiality Policy will be reviewed by
organization personnel.

2.      All organization personnel will be required to sign a Confidentiality Agreement at the time of
hire.



3.     Organization personnel will have access to the minimum necessary protected health information
of patients needed to carry out their duties.

4.     Use and disclosure of protected health information will be carried out according to accepted
policies and procedures. (See "Uses and Disclosures of PHI" Policy No. 5-015.)

5.    Patients will not be discussed by clinical or non-clinical personnel outside of the context of
professional conversation regarding those patients' conditions and care.

6.    Comments and conversations relating to patients made by physicians, nurses, or other
organization personnel will be made in confidential settings. It will be standard, acceptable, and
                     Magnolia Home Health Care Services, Inc.
                         178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                              Tel: 818-566-4411 Fax: 818-566-4404

necessary practice to share information with other members of the care team. The decision to share
information can be aided by considering the intent of the discussion.

7. An agreement and consent for services form will be signed by the patient upon admission.


8. Valid authorizations for use and disclosure of information will be obtained, as required. (See
"Authorizations for Use or Disclosure of PH I" Policy No. 5-016.)


9.     Copies of clinical records, or excerpts of same, cannot be removed from organization except by
subpoena, where statutory law requires it, or on written authorization of the organization. This
confidential information will only be mailed in an envelope designated "confidential."


10.  Patients will be allowed access to their protected health information. (See "Patient Requests for
Access to PHI" Policy No. 5-020.)
                Magnolia Home Health Care Services, Inc.
                    178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                         Tel: 818-566-4411 Fax: 818-566-4404



                                                                     CONFIDENTIALITY OF
                                                              INFORMATION Policy No. 1-015.2
1.   Patients will be allowed access to their protected health information. ( See “Patient
     Requests for Access to PHI” Policy No. 5-020.)
2.   The organization respects the safety and security of patients and their property.
3.   All clinical records will be kept in a locked cabinet/room when not being utilized. The
     Clinical Supervisor or designee will be responsible for the key. No unauthorized individuals
     will be allowed access to clinical records.
4.   The following patient information will be secured after business hours:
     a. Clinical records
     b. Field clinical records
     c. Patient intake information
     d. Minutes of patient care meetings
     e. Performance improvement data
     f.   Clinical notes prior to filing in clinical record
     g. Signed physician (or other authorized licensed independent practitioner) orders
5.   Information contained in performance improvement reports will not contain individual
     patient or personnel information.
6.   Agency will apply appropriate sanctions against any organization personnel who fail to
     comply with its privacy policies and procedures.
                                   Magnolia Home Health Care Services, Inc.
                                          178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                               Tel: 818-566-4411 Fax: 818-566-4404




                                              Home Health Agency
      Outcome and Assessment Information Set (OASIS)€
                                  NOTICE ABOUT PRIVACY
                                  For Patients Who Do Not Have Medicare
                                            or Medicaid Coverage



                As a home health patient, there are a few things
                that you need to know about our collection
                of your personal health care information.
                             Federal and State governments oversee home health care
                             to be sure that we furnish quality home health care
                             services, and that you, in particular, get quality home
                             health care services.
                             We need to ask you questions because
                             we are required by law to collect health information
                             to make sure that you get quality health care services.
                             We will make your information anonymous. That way,
                             the Centers for Medicare & Medicaid Services, the federal
                             agency that oversees this home health agency, cannot know
                             that the information is about you.

                We keep anything we learn about you confidential.


               CAllsl
CEN1FIIS ""MEDICARE •• MElJKAID SEIMCES   I
                            Magnolia Home Health Care Services, Inc.
                                 178 S. Victory Blvd. Suite 207, Burbank, CA 91502
                                      Tel: 818-566-4411 Fax: 818-566-4404



             Home Health Agency
Outcome and Assessment Information Set(OASIS)
 STATEMENT OF PATIENT PRIVACY RIGHTS
As a home health patient, you have the privacy rights listed below.
You have the right to know why we need to ask you questions.

We are required by law to collect health information to make sure:
               1) you get quality health care, and
               2) payment for Medicare and Medicaid patients is correct.

        You have the right to hay e your personal health care information kept
        confidential.

        You may be asked to tell us information about yourself so that€

        we will know which home health services will be best for you. €

        We keep anything we learn about you confidential.€
        This means, only those who are legally authorized to know, or who€
        have a medical need to know, will see your personal health information.€

        You have the right to refuse to answer questions.
        We may need your help in collecting your health information.
        If you choose not to answer, we will fill in the information as best we can. You
        do not have to answer every question to get services.

        You have the right to look at your personal health information.

                    We know how important it is that the information we collect about you is correct. If you
                    think we made a mistake, ask us to correct it.
                    If you are not satisfied with our response, you can ask the Centers for Medicare &
                    Medicaid Services, the federal Medicare and Medicaid agency, to correct your
                    information.


     You can ask the Centers for Medicare & Medicaid Services to see, review, copy, or correct your personal health information w hich
     that Federal agency maintains in its HHA OASIS System of Records. See the back of this Notice for CONTACT INFORMATION. If
     you want a more detailed description of your privacy rights, see the back of this Notice: PRIVACY ACT STATEMENT - HEALTH
     CARE RECORDS.
Magnolia Home Health Care Services, Inc.
  178 S. Victory Blvd. Suite 207, Burbank, CA 91502
       Tel: 818-566-4411 Fax: 818-566-4404

								
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