Privacy Policy

OUR RESPONSIBILITIES:

Lightways Hospice and Serious Illness Care takes the privacy of your health information seriously. Lightways is required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. Lightways is required to abide by the terms of this Notice as are currently in effect.

HOW LIGHTWAYS MAY USE AND DISCLOSURE YOUR HEALTH INFORMATION

The following categories describe different ways that Lightways Hospice and Serious Illness Care uses and discloses your health information. For each category, an explanation of the category is provided, in some cases with examples. Not every use or disclosure in a category will be listed. However, all of the ways Lightways is permitted to use and disclose your health information will fall into one of these categories.

Treatment: Lightways may use and disclose your health information to coordinate care within Lightways and with others involved in your care, such as your attending physician, members of the Lightways interdisciplinary team and other health care professionals who have agreed to assist Lightways in coordinating care. For example, Lightways may disclose your health information to a physician involved in your care who needs information about your symptoms to prescribe appropriate medications. Lightways also may disclose health information about you to individuals outside of Lightways involved in your care, including family members, other relatives, close personal friends, pharmacists, suppliers of medical equipment or other health care professionals. If you do not want information disclosed to certain persons, regardless of their involvement with you, please notify our Privacy Officer.

SUD Treatment Information: 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 the Part 2 Program record for purposes of treatment, payment or health care operations, we may use and disclose your Part 2 Program record for treatment, payment and health care operations purposes as described in this Notice. If we receive or maintain your Part 2 Program record through specific consent you provide to us or another third party, we will use and disclose your Part 2 Program record only as expressly permitted by you in your consent as provided to us. In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order. You have certain rights with respect to SUD treatment records we maintain, including the right to request restrictions on the use and disclosure of those records and the right to file a complaint if you believe your privacy rights have been violated. SUD treatment records governed by 42 CFR Part 2 generally may not be used or disclosed in any civil, criminal, administrative, or legislative proceedings against you unless an authorized written consent is provided or a court order is obtained after proper notice and hearing as required by law. Information that is disclosed pursuant to this Notice may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. If we intend to use or disclose health information for fundraising purposes, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Payment: Lightways may use and disclose your health information to receive payment for the care you receive from Lightways. For example, Lightways may be required by your health insurer to provide information regarding your health care status, your need for care and the care that Lightways intends to provide to you so that the insurer will reimburse you or Lightways.

Health Care Operations: Lightways may use and disclose health information for its own operations to facilitate the functioning of Lightways and as necessary to provide quality care to all Lightways 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 Lightways.
• Fundraising for the benefit of Lightways.

For example, Lightways may use your health information to evaluate its performance, combine your health information with other Lightways patients in evaluating how to more effectively serve all Lightways patients, disclose your health information to members of the Lightways workforce 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 and emails (unless you tell us you do not want to be contacted).

Facility Directory: Lightways may disclose certain information about you, including your name, your general health status, your religious affiliation and where you are in the Lightways facility, in a Lightways directory while you are in the Lightways inpatient facility. Lightways may disclose this information to people who ask for you by name. Please inform us if you do not want your information to be included in the directory.

Fundraising Activities: Lightways may use information about you, including your name, address, telephone number, emails and the dates you received care, in order to contact you to raise money for Lightways. Lightways may also release this information to a related Lightways foundation. If you do not want Lightways to contact you, notify our Privacy Officer at 815-740-4104, and indicate that you do not wish to be contacted. Appointment Reminders: Lightways may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit. Treatment Alternatives: Lightways 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.

As Required by Law: Lightways will disclose your health information when it is required to do so by any Federal, State or local law. Public Health Risks: Lightways 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.
• Notify an employer about an individual who is a member of the employer’s workforce in certain limited situations, as authorized by law. authorities if Lightways believes a patient is the victim of abuse, neglect or domestic violence. Lightways will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure. pg. 3 Updated: 2/16/2026

Health Oversight Activities: Lightways may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, Iicensure or disciplinary action. Lightways, 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.

Judicial And Administrative Proceedings: Lightways 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 Lightways makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

Law Enforcement: As permitted or required by State law, Lightways 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 Lightways has a suspicion that your death was the result of criminal conduct, including criminal conduct at Lightways.
• In an emergency in order to report a crime.

Coroners And Medical Examiners: Lightways 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.

Funeral Directors: Lightways 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, Lightways may disclose your health information prior to and in reasonable anticipation of your death.

Organ; Eye Or Tissue Donation: Lightways 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.

Research Purposes: Lightways may, under certain circumstances, use and disclose your health information for research purposes. Before Lightways discloses any of your health information for research purposes, the project will be subject to an extensive approval process. This process includes evaluating a proposed research project and its use of health information and trying to balance the research needs with your need for privacy. Before Lightways uses or discloses health information for research, the project will have been approved through this research approval process. Additionally, when it is necessary for research purposes and so long as the health information does not leave Lightways, it may disclose your health information to researchers preparing to conduct a research project, for example, to help the researchers look for individuals with specific health needs. Lastly, if certain criteria are met, Lightways may disclose your health information to researchers after your death when it is necessary for research purposes.

Limited Data Set: Lightways may use or disclose a limited data set of your health information, that is, a subset of your health information for which all identifying information has been removed, for purposes of research, public health, or health care operations. Prior to our release, any recipient of that limited data set must agree to appropriately safeguard your health information.

Serious Threat To Health Or Safety: Lightways may, consistent with applicable law and ethical standards of conduct, disclose your health information if Lightways, 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.

Specified Government Functions: In certain circumstances, the Federal regulations authorize Lightways 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.

Worker’s Compensation: Lightways may release your health information for worker’s compensation or similar programs.

OTHER USES OR DISCLOSURES OF HEALTH INFORMATION

Except as otherwise permitted or required by this Notice of Privacy Practices, Lightways will not use or disclose your health information unless you provide written authorization. If you or your representative authorize Lightways to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, Lightways will no longer use or disclose health information about you for the reasons covered by your written authorization, except to the extent that Lightways has taken action in reliance thereon. You understand that Lightways is unable to take back any disclosures it has already made under the authorization, and that Lightways is required to retain our records of the care that it has provided you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

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

Right to request restrictions. You have the right to request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Lightways disclosure of your health information to someone who is involved in your care or the payment of your care. Lightways is not required to agree to your request, unless your request is for a restriction on a disclosure to a health plan for purposes of payment or health care operations (and is not for purposes of treatment) and the medical information you are requesting to be restricted from disclosure pertains solely to a health care item or service for which you have paid out of pocket in full. If you wish to make a request for restrictions, your request must state (l) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply. Please contact our Privacy Officer at 815-740-4104 with your request.

Right to receive confidential communications. You have the right to request that Lightways communicate with you in a certain way. For example, you may ask that Lightways 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 our Privacy Officer at 815-740-4104. Lightways 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 our Privacy Officer at 815-740-4104. lf you request a copy of your health information, Lightways may charge a reasonable fee for copying and assembling costs associated with your request. You have the right to request that Lightways provide you, an entity or a designated individual with an electronic copy of your electronic health record containing your health information, if Lightways uses or maintains electronic health records containing patient health information. Lightways may require you to pay the labor costs incurred by Lightways in responding to your request.

Right to amend health care information. You or your representative has the right to request that Lightways 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 Lightways. A request for an amendment of records must be made in writing to our Privacy Officer at 815-740-4104. Lightways 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 Lightways, if the records you are requesting are not part of Lightways 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 of Lightways, 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 Lightways 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 Privacy Officer, 250 Water Stone Circle, Joliet, Il 60431. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Lightways 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 has a right to a separate paper copy of this Notice at any time, even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact our Privacy Officer at 815-740-4104. You may also obtain a copy of the current version of the Lightways Notice of Privacy Practices at our website, www.lightways.org.

Lightways reserves the right to change this Notice. Lightways reserves the right to make the revised Notice effective for health information we already have about you, as well as any health information we receive in the future. We will post a copy of the current Notice in a clear and prominent location to which you have access. The Notice also is available to you upon request. The Notice will contain, at the end of this document, the effective date. In addition, if Lightways revises the Notice, Lightways will offer you a copy of the current Notice in effect.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE

Lightways has designated the Privacy 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 250 Water Stone Circle, Joliet, II. 60431. The telephone number is 800-360-1817 or 815-740-4104.

COMPLAINTS

You or your personal representative has the right to express complaints to Lightways and to the Secretary of the U.S. Department of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to Lightways should be made in writing to REVISED Privacy Officer, 250 Water Stone Circle, Joliet, II. 60431. To contact the U.S. Department of Health and Human Services the address is Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 North Michigan Ave., Suite 240, Chicago, II 60610. The telephone # 312-886-2359, fax# 312-886-1807, TDD#312-353-5693. Lightways 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.

Joliet Area Community Hospice Corporation (DBA Lightways Hospice and Serious Illness Care)