To request access to your medical records, the Authorization to Release Medical Record Information form must be sent to Arcy Hospice by one of the following methods:
Arcy Hospice will act upon the request no later than 30 calendar days from receiving the individual’s request. If the Hospice is unable to provide access within 30 calendar days, the Hospice may extend the time by no more than an additional 30 days.
To extend the time, the Hospice must, within the initial 30 days, inform the individual in writing of the reasons for the delay and the date that they will provide access.
The Hospice will not charge a fee for retrieving, handling, or processing the patient’s request for access to his or her information.
However, the Hospice may charge a reasonable fee to the patient for preparing a summary at his or her request.
The Hospice may charge a reasonable fee to others for copying, labor, and supplies.
Arcy Hospice may provide the patient with a summary of the protected health information requested, in lieu of providing access to the protected health information or may provide an explanation of the protected health information to which access has been provided.
A written summary of the requested information can be provided for the nominal fee of $20.00.
You may revoke an authorization at any time by submitting a Revocation of Authorization for Use/Disclosure of Protected Health Information (PHI) form to Arcy Hospice.
Arcy Hospice will investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family.
Arcy Hospice will not hamper, compel, discriminate, treat differently, or retaliate against a patient or family for exercising the patient’s rights.
For any complaints, please call the 24/7 Office Number at 463-293-1515 and ask to speak to the Hospice Administrator, Camille Sutton.
The investigation of the complaint will be initiated within 10 calendar days and resolved within 30 calendar days of receipt.
Complaints against the Hospice may be directed to the Texas Health and Human Services Commission (HHSC) Complaint and Incident Intake in any one of the following methods:
This includes a complaint regarding advance directives.
Complaints against the Hospice may be directed to Medicare at Medicare.gov or call the Medicare Beneficiary Ombudsman’s office at 1-800-MEDICARE (1-800-633-4227), or either 1-877-486-2048 or 711 for TTY users. Representatives are available 24 hours a day, seven days a week. If I still need help after talking with a representative, I can ask to have my inquiry referred to the Ombudsman.
This Hospice is Community Health Accreditation Partner (CHAP) accredited, and any complaints regarding the Hospice may be directed to the CHAP hotline at 1-800-656-9656. The hours of operation for CHAP are 8 a.m. – 6 p.m. (EST), Monday through Friday.
Complaints can be made by contacting the Office for Civil Rights (OCR) within 180 days of when the situation occurred.
The complaint must be filed in writing by mail, fax, email, or online via the OCR Complaint Portal.
U.S. Department of Health and Human Services
200 Independence Avenue, S.W. Room 509F HHH Bldg. Washington, D.C. 20201
