NOTICE OF PRIVACY PRACTICES
This notice is to let you know how medical information about you may be used and disclosed. It
also explains how you can get access to your health information. Please read it carefully.
Protecting Your Health Information:
Personal Home Care, LLC (“PHC”) a subsidiary of HomeCentris Healthcare, LLC (“HomeCentris”) is
committed to protecting your health information. So that we can provide services or bill under various
state and federal programs, PHC will ask you for information about your health. This request may be for
information about your medical condition, medications, and physical or mental abilities. This
information will be maintained in your file at PHC’s office or on its secure computer network. PHC
must follow the privacy practices in this Notice. PHC may change its privacy practices and this Notice
from time to time as our policies or privacy regulations change. You may ask PHC for a copy of the
latest privacy notice at any time.
Uses and disclosures of health information required or allowed by law:
PHC’s staff and contractors will only use your health information when doing their jobs. Some examples
of the uses and disclosures of your health information are:

To determine your medical and personal care needs: PHC may use your health
information to assess your needs along with our ability to fulfill them.

To provide services: PHC may use or share your health information in the course of
providing services to you. Information may be shared with other healthcare providers
serving you, such as your physician(s) or other members of your healthcare team,
representatives of federal and state healthcare agencies, or other private organizations
involved in your healthcare. PHC may also share your health information with other
HomeCentris-owned companies if it believes you would benefit from other types of
services, such as skilled nursing or physical therapy, from another of our companies.
Information may also be shared with your family or friends who provide care, if you
so designate.

For Payment: PHC may need to use medical information about you so we may
invoice payors such as Medicare, Medicaid, or an insurance company for the services
you receive. This may not be available depending on your circumstances or if we are
billing you directly. We are permitted by law to disclose the amount of medical
information necessary for us to obtain payment for the care and services provided to
you. Our disclosure of medical information for obtaining payment, may also include
our giving information to your family members who are involved in you care, who
are incurred on your health insurance or who help pay for your care.

For Health Care Operations: We may use and disclose medical information about
you for PHC management decisions. This may be necessary to run PHC and to make
Page 1 of 3
November 2014
sure all of our clients receive quality care. For example, we may use your information
to review our services and to evaluate the qualifications and performance of our staff
in caring for you. We may also combine medical information about many PHC
patients to decide what additional services we should offer, what services are not
needed, and whether improvements can be made.

To provide statistical information under state or federal programs: PHC may use or
share your health information in general terms while reporting statistical information
under state or federal programs. This may include oversight agencies who perform
audits, investigations, inspections and/or license renewal activities.

When required by law: PHC may disclose health information when the law says we
must such as a court-ordered subpoena or in the reporting of communicable disease,
for public health activities or other public safety reasons.

Other personal information: PHC will not voluntarily share any facts that identify
you with anyone except people who need the facts to perform their jobs. Facts that
identify you include your name, social security number, address and telephone
number.
You have a Right to:

Request restrictions: You have a right to ask PHC to restrict the health information
we use or disclose about you. PHC will honor your request if possible, although we
are not required by law to do so. If PHC agrees to a restriction, we will follow it
except in emergency situations.

Request confidential communications: You have the right to ask PHC to send you
information at a different address or in a different way. We must agree to do so, if it
is reasonably easy.

Inspect and Copy: You have a right to see your health information when you request
it in writing. If you want copies of your health information, you must complete a
HIPAA request form and we will charge you a reasonable fee of $1.00 per page for
copying. You have a right to choose what parts of your information you would like
copied and to know the cost of the project before we make copies.

Request amendment: You may ask PHC to correct or add to your health record by
writing to us. PHC may deny the request if we decide (1) the original health
information is correct and complete; (2) the health information you are requesting to
change was not created by PHC and is not part of PHC’s records; or (3) the health
information may not be disclosed. If PHC agrees with the requested changes, we will
change your record and let you know. We will also tell others who need to know
about the change in the health information.

Get a list of disclosures: You have a right to ask for a list of the disclosures of your
health information. Exceptions are: (l) health information that has been used for
treatment; (2) disclosures that we made to you, or were based on your written
authorization; (3) disclosures to law enforcement officials or to correctional facilities.
There will be no charge for up to one of these lists each year.

This Notice: You have the right to receive a paper copy of this Notice and/or an
electronic copy by email.
Page 2 of 3
November 2014

Refuse to provide some or all of the information requested: You have a right to refuse
to give some or all of the information requested. PHC staff can tell you exactly which
facts are needed for us to provide service.
To Report a Problem about our Privacy Practices:
If you believe your privacy rights have been violated, you may file a complaint.
 You can file a complaint with the PHC office.

You can file a complaint with the Secretary of the U.S., Department of Health and Human
Services, Office of Civil Rights.
PHC will take no retaliatory action against you if you make a complaint.
For Further information or questions contact the PHC office at 410-486-5330.
I confirm that I have received this notice:
Client or Authorized Representative: ____________________________
Date: ____________________
Signature of PHC representative______________________________
If unable to get acknowledgment, specify why:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Page 3 of 3
November 2014