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.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices (the “Notice”) describes the Facility’s practices and those of Facility employees, staff, volunteers, and other personnel who are involved in your care. The Facility and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services. Your personal physician may have other policies that he or she follows if he or she sees you outside of the Facility and may use his or her own Notice of Privacy Practices.
THE FACILITY’S PLEDGE REGARDING MEDICAL INFORMATION
The Facility understands that medical information about you and your health is personal. The Facility is committed to protecting medical information about you. In order to provide you with quality care and to comply with certain state and federal legal requirements, the Facility creates a record of the services you receive at the Facility. This Notice applies to all of the records of your care generated by the Facility. This Notice will tell you about the ways in which the Facility may use and disclose medical information about you. It also describes your rights and certain obligations the Facility has regarding the use and disclosure of medical information. The Facility is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
HOW THE FACILITY MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that the Facility may use or disclose protected medical information. For each category of uses and disclosures, the Facility will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways the Facility is permitted to use and disclose information will fall within one of the categories. Some information such as Psychotherapy Notes, certain drug and alcohol information, HIV, or mental health information is entitled to special restrictions.
For Treatment. The Facility may use medical information about you to provide you with medical treatment and to coordinate or manage your medical treatment and any related services. We may disclose information about you to Facility Staff, your Attending Physician, or other providers involved in your treatment. We may also disclose your medical information to family members or other individuals involved in your continuing medical care after you leave the Facility. For example, the Facility may give your Attending Physician access to your health information to assist the physician in treating you.
For Payment. The Facility may use and disclose medical information about you so that the Facility can get paid for the treatment and services you receive at the Facility. For example, the Facility may need to give information to your health plan or to the Medi-Cal or Medicare program about treatment you receive at the Facility so that they will pay the Facility or reimburse you for your care. The Facility may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.
For Health Care Operations. The Facility may use and disclose medical information about you to carry out activities that are necessary for Facility operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, the Facility may use medical information to review treatment and services provided at the Facility or to evaluate the performance of its staff and contractors in caring for you.
Facility Directory. The Facility may list your name, room number, general description of your condition (excluding medical information), and your religious affiliation in the Facility’s Directory of residents.
Please inform the facility if you would NOT like your information to be listed in the Facility Directory.
To Individuals or Family Members Involved in Your Health Care
Unless you object, the Facility may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. The Facility may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.
Emergencies. The Facility may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, the Facility will use its professional judgment to decide whether this disclosure is in your best interest.
Please inform the facility if you would like to object to this disclosure.
For Fundraising Activities. The Facility may use medical information about you to contact you about Facility sponsored activities including fundraising events. We will only use contact information such as your name, address, and phone number.
As Required By Law. The Facility will disclose your health information when required to do so by federal, state or local law.
Workers Compensation. The Facility may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
For Public Health Activities. The Facility may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
For Health Oversight Activities. The Facility may disclose medical information about you to a health oversight agency for activities authorized by law.
For Lawsuits and Disputes. The Facility may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Disclosure to Law Enforcement. If asked to do so by law enforcement and as authorized or required by law, the Facility may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at the Facility; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Decedents. The Facility may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Facility may also release medical information about you to funeral directors. The Facility may also release information to any individual known to the Facility as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
For Specialized Government Functions. The Facility may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.
Information About Inmates/Individuals in Custody. If you are an inmate or under the custody of a law enforcement official, the Facility may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
Disclosure For Threats to Health and Safety. In certain circumstances, the Facility may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
SPECIAL PROVISIONS RELATED TO RESDIENT PRIVACY
Psychotherapy Notes. The Facility will not release any Psychotherapy Notes without a specific authorization from you that allows the Facility to release the notes.
Marketing. The Facility will not release your medical information for marketing purposes without an authorization from you.
Sale of Medical Information. The Facility will not sell your medical information without an authorization from you.
Substance Abuse. The Facility will not disclose identity and records of the diagnosis, prognosis or treatment of residents that are maintained in connection with performing any drug abuse treatment or prevention efforts without your written consent.
HIV/AIDS Test Results. The Facility will not disclose the results of an HIV/AIDS test unless you give the Facility specific written authorization. The Facility may disclose HIV/AIDS test results without your specific authorization as required by state or federal reporting laws.
You have the following rights regarding your medical information. In order to exercise these rights, you must contact The HIPAA Privacy Officer at the Facility. You may be asked to submit a written request.
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.
Amendment. If you feel that medical information about you is incorrect or incomplete, you may ask the Facility to amend the information.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures that we may have made of your medical information.
Right to Request Restrictions. You have the right to request a restriction or limitation on medical information that the Facility uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that the Facility may disclose to family members or friends involved in your care.
Request Confidential Communications. You have the right to request that the Facility communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.
Receive a Copy. You have the right to obtain a copy of this notice.
CHANGES TO THIS NOTICE
The Facility reserves the right to change the terms of this Notice at any time. The Facility reserves the right to make the revised or changed notice effective for medical information the Facility already has about you as well as any information the Facility receives in the future. The Facility will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
If you have any questions or believe that your privacy rights have been violated, you may contact the Facility’s HIPAA Privacy Officer in person or mail a written summary of your concern to the address listed above.
You may also file a written complaint with the Department of Health and Human Services at the following address:
Office of Civil Rights, DHHS
90 7th Street, Suite 4-100
San Francisco, CA 94103
Phone: 415-437-8310 Fax: 415-437-8329
You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide the Facility permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission the Facility will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if the Facility has already acted in reliance on your permission. You understand that the Facility is unable to take back any disclosure the Facility has already made with your permission and that the Facility is required to retain its records of the care that the Facility provided to you.