NOTICE OF 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.

 

If you have any questions regarding this notice, please contact the Fiscal Services Director, 420 Main Street, P.O. Box 621, Rochester, IN 46975. Telephone: (574) 224-4673.

 

 

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

 

Other than is stated below, Hope Hospice, Inc. will not disclose your health information other than with your written authorization. If you or your representative authorizes Hope Hospice, Inc. to use or disclose your health information, you may revoke that authorization in writing at any time.

 

USE AND DISCLOSURE OF HEALTH INFORMATION

 

Hope Hospice, Inc. may use your health information, information that constitutes protected health information as defined in the HIPAA Privacy Rule Act of 1996, for purposes of providing your treatment, obtaining payment for your care and conducting health care operations. Hope Hospice, Inc. has established policies to guard against unnecessary disclosure of your health information.

 

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION -- WITH YOUR PERMISSION -- MAY BE USED AND DISCLOSED:

 

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

 

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

 

To Conduct Health Care Operations. Hope Hospice, Inc. may use and disclose health information for its own operations in order to facilitate the function of Hope Hospice, Inc. and as necessary to provide quality care to all of Hope Hospice, Inc.'s 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 Hope Hospice, Inc.

 

For example Hope Hospice, Inc. may use your health information to evaluate its staff performance, combine your health information with other Hospice patients in evaluating how to more effectively serve all Hospice patients, disclose your health information to Hospice 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 community information mailings (unless you tell us you do not want to be contacted).

 

For Appointment Reminders. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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 ONLY OTHER CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION -- WITHOUT YOUR PERMISSION -- MAY BE USED AND DISCLOSED:

 

When Legally Required. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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 workforce as legally required

 

To Report Abuse, Neglect Or Domestic Violence. Hope Hospice, Inc. is allowed to notify government authorities if Hope Hospice, Inc. believes a patient is the victim of abuse, neglect or domestic violence. Hope Hospice, Inc. 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. Hope Hospice, Inc. may disclose your health information to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Hope Hospice, Inc., 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. Hope Hospice, Inc. 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 Hope Hospice, Inc. 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, Hope Hospice, Inc. 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 Hope Hospice, Inc. has a suspicion that your death was the result of criminal conduct including criminal conduct at Hope Hospice, Inc.

· In an emergency in order to report a crime

 

To Coroners And Medical Examiners. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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, Hope Hospice, Inc. may disclose your health information prior to and in reasonable anticipation of your death.

 

If You Have Previously Elected To Donate Organ, Eye Or Tissue. Hope Hospice, Inc. 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.

 

In The Event Of A Serious Threat To Health Or Safety. Hope Hospice, Inc. may, consistent with applicable law and ethical standards of conduct, disclose your health information if Hope Hospice, Inc., 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 Hope Hospice, Inc. 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. Hope Hospice, Inc. may release your health information for worker's compensation or similar programs.

 

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

 

You have the following rights regarding your health information that Hope Hospice, Inc. 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 Hope Hospice, Inc.'s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Hope Hospice, Inc. is not required to agree to your request. If you wish to make a request for restrictions, please contact the Fiscal Services Director.

 

· Right to receive confidential communications. You have the right to request that Hope Hospice, Inc. communicate with you in a certain way. For example, you may ask that Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. If you request a copy of your health information, Hope Hospice, Inc. may charge a reasonable fee for copying and assembling costs associated with your request.

 

· Right to amend health care information. You or your representative has the right to request that Hope Hospice, Inc. 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 Hope Hospice, Inc. A request for an amendment of records must be made in writing to the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. Hope Hospice, Inc. 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 Hope Hospice, Inc., if the records you are requesting are not part of Hope Hospice, Inc.'s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Hope Hospice, Inc., 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 Hope Hospice, Inc. 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 the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. 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. Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. You or your representative may also obtain a copy of the current version of Hope Hospice, Inc.'s Notice of Privacy Practices at its website, www.rtcol.com/~hospice.

 

DUTIES OF HOPE HOSPICE

 

Hope Hospice, Inc. 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. Hope Hospice, Inc. is required to abide by the terms of this as may be amended from time to time. Hope Hospice, Inc. 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 Hope Hospice, Inc. changes its Notice, Hope Hospice, Inc. 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 Hope Hospice, Inc. and to the Secretary of Department of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to Hope Hospice, Inc. should be made in writing to the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. Hope Hospice, Inc. 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.

 

CONTACT PERSON

 

Hope Hospice, Inc. has designated the Fiscal Services Director as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 420 Main Street, P.O. Box 621, Rochester, IN 46975, (574) 224-4673.

 

EFFECTIVE DATE

 

This Notice is effective April 14, 2003.

 

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE FISCAL SERVICES DIRECTOR, 420 MAIN STREET, P.O. BOX 621, ROCHESTER, IN 46975, (574) 224-4673.

 

·  E-mail: hospice@rtcol.com

           

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NOTICE OF HOPE HOSPICE PRIVACY PRACTICES

Hope Hospice, Inc.

Fulton County, Indiana

_______________________________________________________________________________________

NOTICE OF 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.

If you have any questions regarding this notice, please contact the Fiscal Services Director, 420 Main Street, P.O. Box 621, Rochester, IN 46975. Telephone: (574) 224-4673.

_______________________________________________________________________________________

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than is stated below, Hope Hospice, Inc. will not disclose your health information other than with your written authorization. If you or your representative authorizes Hope Hospice, Inc. to use or disclose your health information, you may revoke that authorization in writing at any time.

USE AND DISCLOSURE OF HEALTH INFORMATION

Hope Hospice, Inc. may use your health information, information that constitutes protected health information as defined in the HIPAA Privacy Rule Act of 1996, for purposes of providing your treatment, obtaining payment for your care and conducting health care operations. Hope Hospice, Inc. has established policies to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION -- WITH YOUR PERMISSION -- MAY BE USED AND DISCLOSED:

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

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

To Conduct Health Care Operations. Hope Hospice, Inc. may use and disclose health information for its own operations in order to facilitate the function of Hope Hospice, Inc. and as necessary to provide quality care to all of Hope Hospice, Inc.'s 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 Hope Hospice, Inc.

For example Hope Hospice, Inc. may use your health information to evaluate its staff performance, combine your health information with other Hospice patients in evaluating how to more effectively serve all Hospice patients, disclose your health information to Hospice 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 community information mailings (unless you tell us you do not want to be contacted).

For Appointment Reminders. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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 ONLY OTHER CIRCUMSTANCES UNDER WHICH YOUR HEALTH INFORMATION -- WITHOUT YOUR PERMISSION -- MAY BE USED AND DISCLOSED:

When Legally Required. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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 workforce as legally required

To Report Abuse, Neglect Or Domestic Violence. Hope Hospice, Inc. is allowed to notify government authorities if Hope Hospice, Inc. believes a patient is the victim of abuse, neglect or domestic violence. Hope Hospice, Inc. 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. Hope Hospice, Inc. may disclose your health information to a health oversight hospice for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Hope Hospice, Inc., 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. Hope Hospice, Inc. 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 Hope Hospice, Inc. 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, Hope Hospice, Inc. 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 Hope Hospice, Inc. has a suspicion that your death was the result of criminal conduct including criminal conduct at Hope Hospice, Inc.

· In an emergency in order to report a crime

To Coroners And Medical Examiners. Hope Hospice, Inc. 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. Hope Hospice, Inc. 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, Hope Hospice, Inc. may disclose your health information prior to and in reasonable anticipation of your death.

If You Have Previously Elected To Donate Organ, Eye Or Tissue. Hope Hospice, Inc. 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.

In The Event Of A Serious Threat To Health Or Safety. Hope Hospice, Inc. may, consistent with applicable law and ethical standards of conduct, disclose your health information if Hope Hospice, Inc., 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 Hope Hospice, Inc. 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. Hope Hospice, Inc. may release your health information for worker's compensation or similar programs.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that Hope Hospice, Inc. 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 Hope Hospice, Inc.'s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Hope Hospice, Inc. is not required to agree to your request. If you wish to make a request for restrictions, please contact the Fiscal Services Director.

· Right to receive confidential communications. You have the right to request that Hope Hospice, Inc. communicate with you in a certain way. For example, you may ask that Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. If you request a copy of your health information, Hope Hospice, Inc. may charge a reasonable fee for copying and assembling costs associated with your request.

· Right to amend health care information. You or your representative has the right to request that Hope Hospice, Inc. 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 Hope Hospice, Inc. A request for an amendment of records must be made in writing to the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. Hope Hospice, Inc. 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 Hope Hospice, Inc., if the records you are requesting are not part of Hope Hospice, Inc.'s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Hope Hospice, Inc., 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 Hope Hospice, Inc. 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 the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. 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. Hope Hospice, Inc. 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 the Fiscal Services Director at (574) 224-4673. You or your representative may also obtain a copy of the current version of Hope Hospice, Inc.'s Notice of Privacy Practices at its website, www.rtcol.com/~hospice.

DUTIES OF HOPE HOSPICE

Hope Hospice, Inc. 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. Hope Hospice, Inc. is required to abide by the terms of this as may be amended from time to time. Hope Hospice, Inc. 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 Hope Hospice, Inc. changes its Notice, Hope Hospice, Inc. 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 Hope Hospice, Inc. and to the Secretary of Department of Health and Human Services if you or your representative believes that your privacy rights have been violated. Any complaints to Hope Hospice, Inc. should be made in writing to the Fiscal Services Director at 420 Main Street, P.O. Box 621, Rochester, IN 46975. Hope Hospice, Inc. 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.

CONTACT PERSON

Hope Hospice, Inc. has designated the Fiscal Services Director as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 420 Main Street, P.O. Box 621, Rochester, IN 46975, (574) 224-4673.

EFFECTIVE DATE

This Notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE FISCAL SERVICES DIRECTOR, 420 MAIN STREET, P.O. BOX 621, ROCHESTER, IN 46975, (574) 224-4673.

  • E-mail: hospice@rtcol.com
  • Back to Hope Hospice Home Page