A. Uses and Disclosures for Treatment Payment and Health Care Operations.
We may use and disclose PHI, but not your ‘highly confidential information’ (defined in Section IV.C), in order to treat you, obtain payment for services provided to you and conduct our health care operations as detailed below:
- Treatment
We use and disclose your PHI to provide treatment and other services to you. For
example, to diagnose and treat your injury or illness. In addition, we may
contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of
interest to you. We may also disclose PHI to other providers involved in your
treatment.
- Payment
We may use and disclose your PHI to obtain payment for services that we provide
to you. For example, disclosures to claim and obtain payment from your health
insurer, HMO, or other company that arranges or pays the cost of some or all of
your health care (your 'Payor') to verify that your payor will pay for health
care.
- Health Care Operations
We may use and disclose your PHI for our health care operations, which include
internal administration and planning and various activities that improve the
quality and cost effectiveness of the care that we deliver to you. For example,
we may use PHI to evaluate the quality and competence of our physicians, nurses
and other health care workers. We may disclose PHI to our Privacy Office Risk
Management Officer in order to resolve any complaints you may have and ensure
that you have a comfortable visit with us.
We may also disclose PHI to your other health care providers when such
PHI is required for them to treat you, receive payment for services they
render to you, or conduct certain health care operations, such as
quality assessment and improvement activities, reviewing the quality and
competence of health care professionals, or for health care fraud and
abuse detection or compliance. In addition, we may share PHI with our
business associates who perform treatment, payment and health care
operations services on our behalf.
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B. Use or Disclosure for Directory of Individuals in the Hospital.
We may include your name, location in the hospital, general health
condition and religious affiliation in a patient directory without
obtaining your authorization unless you object to inclusion in the
directory or are located in a specific ward, wing or unit where the
identification of which would reveal that you are receiving treatment
for mental health and developmental disabilities. Information in the
directory may be disclosed to anyone who asks for you by name or members
of the clergy; provided, however, that religious affiliation will only
be disclosed to members of the clergy.
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C. Disclosure to Relatives, Close Friends and Other Caregivers.
We may use or disclose your PHI to a family member, other relative, a
close personal friend or any other person identified by you when you are
present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide
you with the opportunity to object to the disclosure and you do not
object; or (3) reasonably infer that you do not object to the
disclosure. If you are not present, or the opportunity to agree or
object to a use or disclosure cannot practicably be provided because of
your incapacity or an emergency circumstance, we may exercise our
professional judgment to determine whether a disclosure is in your best
interests. If we disclose information to a family member, other relative
or a close personal friend, we would disclose only information that we
believe is directly relevant to the person’s involvement with your
health care or payment related to your health care. We may also disclose
your PHI in order to notify (or assist in notifying) such persons of
your location or general condition.
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D. Public Health Activities.
We may disclose your PHI for the following public health activities: (1) to
report health information to public health authorities for the purpose
of preventing or controlling disease, injury or disability; (2) to
report child abuse and neglect to public health authorities or other
government authorities authorized by law to receive such reports; (3) to
report information about products and services under the jurisdiction of
the U.S. Food and Drug Administration; (4) to alert a person who
may have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading a disease or condition; and (5) to
report information to your employer as required under laws addressing
work-related illnesses and injuries or workplace medical surveillance.
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E. Victims of Abuse, Neglect or Domestic Violence.
If we reasonably believe you are a victim of abuse, neglect or domestic
violence, we may disclose your PHI to a governmental authority,
including a social service or protective services agency, authorized by
law to receive reports of such abuse, neglect, or domestic violence.
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F. Health Oversight Activities.
We may disclose your PHI to a health oversight agency that oversees the
health care system and is charged with responsibility for ensuring
compliance with the rules of government health programs such as Medicare
or Medicaid.
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G. Judicial and Administrative Proceedings.
We may disclose your PHI in the course of a judicial or administrative
proceeding in response to a legal order or other lawful process.
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H. Law Enforcement Officials.
We may disclose your PHI to the police or other law enforcement
officials as required or permitted by law or in compliance with a court
order or a grand jury or administrative subpoena.
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I. Decedents.
We may disclose your PHI to a coroner or medical examiner as authorized
by law.
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J. Organ and Tissue Procurement.
We may disclose your PHI to organizations that facilitate organ, eye or
tissue procurement, banking or transplantation.
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K. Research.
We may use or disclose your PHI without your consent or authorization if
our Institutional Review Board approves a waiver of authorization for
disclosure.
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L. Health or Safety.
We may use or disclose your PHI to prevent or lessen a serious and
imminent threat to a person’s or the public’s health or safety.
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M. Specialized Government Functions.
We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
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N. Workers Compensation.
We may disclose your PHI as authorized by and to the extent necessary to comply with California law relating to workers compensation or other similar programs.
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O. As Required by Law.
We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
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A. Use or Disclosure with Your Authorization.
For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization on
our authorization form ('Your Authorization'). For instance, you will need to execute an authorization form before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
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B. Marketing.
We must also obtain your written authorization ('Your Marketing
Authorization') prior to using your PHI to send you any marketing
materials. (We can, however, provide you with marketing materials in a
face-to-face encounter without obtaining Your Marketing Authorization.
We are also permitted to give you a promotional gift of nominal value,
if we so choose, without obtaining Your Marketing Authorization.) In
addition, we may communicate with you about products or services
relating to your treatment, case management or care coordination, or
alternative treatments, therapies, providers or care settings without
Your Marketing Authorization.
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C. Uses and Disclosures of Your Highly Confidential Information.
In addition, federal and state law requires special privacy protections for certain highly confidential information about you, including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic and elder abuse or (9) is about sexual assault.
In order for us to disclose your highly confidential information for a
purpose other than those permitted by law, we must obtain your written
authorization. In accordance with federal and California law, there are
specific situations in which highly confidential information may be
released without the patient’s authorization:
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1. Substance Abuse Information May be released in the Following Situations:
- Program Personnel: Communication of information between or among personnel
who need such information to diagnose, treat, or refer for treatment of alcohol
or drug abuse, if the communications are within a program or between a program
and an entity that has direct administrative control over the program.
- Qualified Service Organizations: Communications between a program and a
qualified service organization of information needed by the organization to
provide services to the program.
- Crimes on Program Premises or Against Program Personnel: Communications from
program personnel to law enforcement officers that are directly related to a
patient’s commission of a crime on program premises or against program personnel
or to a threat to commit such crime and are limited to the circumstances of the
incidents.
- Child Abuse Reports: Reports of suspected child abuse and neglect under
California law to the appropriate authorities.
- Veterans Administration and Armed Forces: Certain exceptions apply to
records and information maintained by the Veterans’ Administration and Armed
Forces.
- Medical Emergencies: Information may be disclosed to medical personnel who
need the information to treat a condition which poses an immediate threat to the
health of any individual and which requires immediate medical intervention.
- Research Activities: Information may be disclosed for the purpose of
conducting scientific research if the program director determines that the
recipient of the patient-identifiable information is qualified to conduct the
research and has a research protocol under which the patient identifiable
information will be maintained in accordance with specified security
requirements under the regulations.
- Audit and Evaluation Activities: Information may be disclosed for audit by
an appropriate federal, state or local governmental agency that provides
financial assistance to the program or is authorized by law to regulate its
activities; a third party payer covering patients in the program; a private
person or entity that provides financial assistance to the program; a peer
review organization performing utilization or quality control review; or an
entity authorized to conduct a Medicare or Medicaid audit or evaluation.
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2. Reports of suspected child abuse or neglect and information contained therein may be disclosed only to:
- Law enforcement
- Child welfare agency
- Licensing agency (the state agency responsible for licensing the agency in question).
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3. Reports of Elder and Dependent Adult Abuse may be Disclosed Only in These Following Situations:
- Information relevant to the incident of elder or dependent adult abuse may
be given to an investigator from an adult protective services agency, a local
law enforcement agency, the Bureau of Medi-Cal fraud, or investigators from the
Department of Consumer Affairs, Division of Investigation who are investigating
the known or suspected case of elder or dependent adult abuse.
- Persons who are trained and qualified to serve on multi-disciplinary
personnel teams may disclose to one another information and records that are
relevant to the prevention, identification, or treatment of abuse of elderly or
dependent adults.
- The health care provider may disclose medical information pursuant to the
Confidentiality of Medical Information Act.
- The health care provider may disclose mental health information pursuant to
California law.
- Information from elder abuse reports and investigations, except for the
identity of persons who have made reports.
- Information pertaining to reports by health practitioners of persons
suffering from physical injuries inflicted by means of a firearm or of persons
suffering physical injury where the injury is a result of assaultive or abusive
conduct.
- Information protected by the physician-patient or psychotherapist patient
privileges.
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4. HIV Test Results May be Disclosed to the Following Persons Without the Written Authorization of the Subject of the Test:
- To the subject of the test or the subject’s legal representative,
conservator, or to any person authorized to consent to the act.
- To a test subject’s provider of health care, as defined by California law.
- To an agent or employee of the test subject’s provider of health care who
provides direct patient care and treatment.
- To a provider of health care who procures, processes, distributes or uses a
human body part donated pursuant to the Uniform Anatomical Gift Act.
- To the designated officer of an emergency response employee (as those terms
are used in the Ryan White Comprehensive AIDS Resources Emergency Act of 1990).
- To a procurement organization, a coroner, or a medical examiner in
conjunction with organ donation.
- To a health care worker who has been exposed to the potentially infectious
materials of a patient provided that strict procedures for testing and consent
are followed.
- To specified categories of persons, where the test has been performed on a
criminal defendant pursuant to California law.
- To an officer in charge of adult correctional or juvenile detention
facilities that an inmate or minor at such facility has been exposed or infected
by the AIDS virus or has an AIDS-related condition or other communicable
disease.
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5. Communicable Diseases:
- Health care facilities and clinics must establish administrative procedures
to assure that reports are made to the local health officer.
- Where no health care provider is in attendance, any individual having
knowledge of a person who is suspected to have a disease reportable under
California law, may make a report to the local health officer for the
jurisdiction in which the patient resides.
- Disease notifications must include, if known, the following information: the
name of the disease or condition; the date of onset; the date of diagnosis; the
name, address, telephone number, occupation, race/ethnic group, social security
number, sex, age, and the date of birth of the patient; the date of death when
applicable; and the name, address and telephone number of the person making the
report.
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6. Release of Mental Health and Developmental Disability Information Requires the Written Authorization of the Patient Only to the Persons Listed Below:
- The patient’s attorney, upon presentation of release of information
authorization signed by the patient. If the patient is unable to sign, the
facility may release records to the attorney, if the staff has determined that
the attorney represents the interests of the patient.
- A person designated by the patient, provided the professional in charge of
the patient gives approval; patient consent is not required.
- A person designated in writing by a patient's parent, guardian, conservator,
or guardian ad litem if the patient is a minor, ward or conservatee; patient’s
consent is not required.
- A professional person who does not have the medical or psychological
responsibility for the patient’s care and who is not employed by the facility
that maintains the record.
- A life or disability insurer provided the patient designates the insurer in
writing.
- A qualified physician or psychiatrist who represents an employer to which
the patient has applied for employment unless the physician or administrative
officer responsible for the care of the patient deems the release contrary to
the best interests of the patient.
- A probation officer charged with the evaluation of a person after his or her
conviction of a crime if the person has been previously confined in, or
otherwise treated by, a facility.
- An applicant for, or recipient of, services from the state Department of
Developmental Services (or the person’s authorized representative) for the
purpose of appealing an adverse eligibility or benefits decision.
- A county patients’ rights advocate upon presentation of written
authorization, signed by the patient who is the advocate's 'client' or by the
'client's' guardian ad litem.
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A. For Further Information /Complaints.
If you desire further information about your privacy rights, are
concerned that we have violated your privacy rights or disagree with a
decision that we made about access to your PHI, you may contact our
Privacy Office. You may also file written complaints with the Director,
Office for Civil Rights of the U.S. Department of Health and Human
Services. Upon request, the Privacy Office will provide you with the
correct address for the Director. We will not retaliate against you if
you file a complaint with us or the Director.
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B. Right to Request Additional Restrictions.
You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care
operations, (2) to individuals (such as a family member, other relative, close personal friend or any other
person identified by you) involved with your care or with payment related to your care, or (3) to notify or
assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a
requested restriction. If you wish to request additional restrictions,
please obtain a request form from the Health Information Management (H.I.M.)
Director and submit the completed form to the H.I.M. Director. We will
send you a written response.
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C. Right to Receive Confidential Communications.
You may request, and we will accommodate, any reasonable written request
for you to receive your PHI by alternative means of communication or at
alternative locations.
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D. Right to Revoke Your Authorization.
You may revoke your authorization, your marketing authorization or any
written authorization obtained in connection with your highly
confidential information, except to the extent that we have taken action
in reliance upon it, by delivering a written revocation statement to the
H.I.M. Director identified below.
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E. Right to Inspect and Copy Your Health Information.
You may request access to your medical record file and billing records
maintained by us in order to inspect and request copies of the records.
Under limited circumstances, we may deny you access to a portion of your
records. You should take note that, if you are a parent or legal
guardian of a minor, certain portions of the minor’s medical record will
not be accessible to you (for example, records pertaining to health care
services for which the minor can lawfully give consent and therefore for
which the minor has the right to inspect or obtain copies of the record
(i.e. abortion or mental health treatment); or the health care provider
determines, in good faith, that access to the patient records requested
by the representative would have a detrimental effect on the provider’s
professional relationship with the minor patient or on the minor’s
physical safety or psychological well-being. If you desire access to
your records, please obtain a record request form from the Medical
Records Office and submit the completed form to the Medical Records
Office. If you request copies, we will charge you twenty-five cents
($0.25) for each page copied and the actual costs for clerical time and
copies of x-rays and EEG, ECG and EMG tracings. We will also charge you
for our postage costs, if you request that we mail the copies to you.
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F. Right to Amend Your Records.
You have the right to request that we amend Protected Health Information
maintained in your medical record file or billing records. If you desire
to amend your records, please obtain an amendment request form from the
Medical Records Office and submit the completed form to the Medical
Records Office. We will comply with your request unless we believe that
the information that would be amended is accurate and complete or other
special circumstances apply.
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G. Right to Receive an Accounting of Disclosures
Upon request, you may obtain an accounting of certain disclosures of your PHI
made by us during any period of time prior to the date of your request
provided such period does not exceed six years and does not apply to
disclosures that occurred prior to April 14, 2003. If you request an
accounting more than once during a twelve (12) month period, we will
charge you the actual costs of the preparing of the accounting statement
for each subsequent request. |
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H. Notification of Unlawful or Unauthorized Access, Use, or Disclosure.
In the event of an unlawful or unauthorized access, use or disclosure of your Protected
Health Information in violation of the California Confidentiality of Medical Information
Act and related privacy laws occurs, reasonable efforts will be undertaken to advise you
of the same within five (5) days of the detection by the Hospital of any such breach of
privacy.
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I. Right to Receive Paper Copy of this Notice.
Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
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