Privacy Notice 2003

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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.

I. Our Duty to Safeguard Your Protected Health Information

We are committed to preserving the privacy and confidentiality of your health information whether created by us or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your health information. Copies of our privacy policies and procedures are maintained in the Health Information Management Department. We are required by state and federal regulations to abide by the privacy practices described in this notice including any future revisions that we may make to the notice as may become necessary or as authorized by law.

Individually identifiable information about your past, present, or future health or condition, the provisions of health care to you, or payment for the health care treatment or services you receive is considered protected health information (PHI). As such, we are required to provide you with this Privacy Notice that: 1) contains information regarding our privacy practices;
2) explains how, when and why we may use or disclose your protected health information; 3) and your rights and our obligations regarding any such uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum necessary protected health information to accomplish the intended purpose of the use or disclosure of such information.

We reserve the right to change this notice at any time and to make the revised or changed notice effective for health information we already have about you, as well as any information we receive in the future about you. Should we revise/change this Privacy Notice, we will post a copy of the new/revised Privacy Notice on our information board. You also may request and obtain a copy of any new/revised Privacy Notice from the Health Information Management Department or Admissions.

Should you have questions concerning our Privacy Notices, the names, addresses, telephone numbers, website addresses, etc., of whom you should contact are listed on the last page of this document.

II. How We May Use and Disclose Your Protected Health Information

We use and disclose protected health information for a variety of reasons. We have a limited right to use and/or disclose your health information for purposes of treatment, payment, or for the operations of our facility. For other uses, you must give us your written authorization to release your protected health information unless the law permits or requires us to make the use or disclosure without your authorization.

Should it become necessary to release your protected health information to an outside party, we will require the party to have a signed agreement with us that the party will extend the same degree of privacy protection to your information as we do.

The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health information. Where appropriate, we have included examples of the different types of uses or disclosures. These include:

1. Use and Disclosures Related to Treatment:

We may disclose your protected health information to those who are involved in providing medical and nursing care services and treatments to you. For example we may release health information about you to our nurses, nursing assistants, medication aides/technicians, medical and nursing students, therapists, pharmacists, medical records personnel, consultants, physicians, etc. We may also disclose your protected health information to outside entities performing other services relating to your treatment; such as diagnostic laboratories, home health/hospice agencies, family members, etc.

2. Use and Disclosures Related to Payment:

We may use or disclose your protected health information to bill and collect payment for services or treatments we provided to you. For example, we may contact your insurance facility, health plan, or another third party to obtain payment for services we provided to you.

3. Use and Disclosures Related to Health Care Operations:

We may use or disclose your protected health information to perform certain functions within our facility should these uses or disclosures become necessary to operate our facility, and to ensure that you, and others we provide care and services, to continue to receive quality care and services. For example, we may take your photograph for medication identification purposes or use your health information to evaluate the effectiveness of the care and services you are receiving. We may disclose your protected health information to our staff (nurses, nursing assistants, physicians, staff consultants, therapists, etc.) for auditing, care planning, treatment, and learning purposes. We may also combine your health information with information from other health care providers to study how our facility is performing in comparison to like facilities or what we can do to improve the care and services we provide to you. When information is combined, we remove all information that would identify you so that others may use the information in developing research on the delivery of health care services without learning your identity.

4. Use and Disclosures Related to Fundraising Activities:

We may use a limited amount of your protected health information when raising money for our facility and its operations. We may also disclose this information to a foundation related to the facility so that the foundation may contact you to raise money on behalf of our facility. The information we may use will be limited to your name, address, telephone number, and dates for which you received treatment or services at our facility. If you do not wish to be contacted for participation in fundraising activities or have this information provided to our affiliated foundation, you must provide us with a written notification. The person to contact or department to provide written notification is listed on the last page of this notice.

5. Use and Disclosures Related to Treatment Alternatives, Health-Related Benefits and Services:

We may use or disclose your protected health information for purposes of contacting you, to inform you of treatment alternatives, or health-related benefits and services that may be of interest to you. For example, a newly released medication or treatment that has a direct relationship to your treatment or medical condition.

III. Uses and Disclosures Requiring Your Written Authorization

For uses and disclosures of your protected health information beyond treatment, payment and operations purposes, we are required to have your written authorization, except as permitted by law. You have the right to revoke an authorization at any time and / or to stop future uses or disclosures of your information, except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. The address and telephone number of the department or person to contact is located on the last page of this document.
Examples of uses or disclosures that would require your written authorization include, but are not limited to, the following:

1. A request to provide certain information to another individual or facility.
2. A request to provide certain information to an insurance or pharmaceutical facility for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you.
3. A request to provide your protected health information to an attorney for use in a civil litigation claim.

IV. Uses or Disclosures of Information Based Upon Your Verbal Agreement

In the following situations, we may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are unable to object (because you were not present or you were incapacitated, etc.), disclosure may be made if it is consistent with any prior expressed wishes, and disclosure is determined to be in your best interest. When a disclosure is made, based on these or emergency situations, we will only disclose health information relevant to the person’s involvement in your care. For example, if you are sent to the emergency room, we may only inform the person that you suffered an apparent heart attack, stroke, etc., and/or we may provide information on your prognosis or progress. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so.

1. Information Used or Disclosed in the Facility Directory:

We may use or disclose your name, unit or room number, and religious affiliation in our facility directory. We may also disclose your religious affiliation to a member of the clergy. Information concerning your general condition or room location may be provided to callers or visitors when they ask for you by name. You may object to the release of this information by contacting the Health Information Management Department or Privacy Officer / Administrator at the address, and telephone number listed on the last page of this document.

2. Information Disclosed to Family Members, Friends or Others Involved in Your Care:
We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your family and/or friends about your general condition, location, and/or status (i.e., alive or dead). You may object to the release of this information by contacting the HIMD or the Privacy Officer / Administrator at the address, and telephone number listed on the last page of this document. (See also Section VI, paragraph 1.)

V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization

State and federal laws and regulations either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorization include the following:

1. When Required by Law:

We may disclose your protected health information when a federal, state or local law requires that we report information about suspected abuse, neglect, or domestic violence, reporting adverse reactions to medications or injury from a health care product, or in response to a court order or subpoena.

2. For Public Health Activities for the Purpose of Preventing or Controlling Disease, Injury or Disability:

We may disclose your protected health information when we are required to collect information about diseases or injuries (e.g., your exposure to a disease or your risk for spreading or contracting a communicable disease or condition, product recalls, or to report vital statistics (e.g., births/deaths) to the public health authority).

3. For Health Oversight Activities:

We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, the state agency responsible for inspecting our facility or to other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents or to ensure that we are in compliance with applicable state and federal laws and regulations and civil rights issues.

4. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations or Tissue Banks:

We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We may also disclose your health information to a funeral director for the purposes of carrying out your wishes and/or for the funeral director to perform his/her necessary duties.

If you are an organ donor, we may disclose your protected health information to the organization that will handle your organ, eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation.

5. For Research Purposes:

We may disclose your protected health information for research purposes only when a privacy board has approved the research project. However, we may use or disclose your protected health information to individuals preparing to conduct an approved research project in order to assist such individuals in identifying persons to be included in the research project. Researchers identifying persons to be included in the research project will be required to conduct all activities onsite. If it becomes necessary to use or disclose information about you that could be used to identify you by name, we will obtain your written authorization before permitting the researcher to use your information. Researchers will be required to sign a Confidentiality and Non-Disclosure Agreement form before being permitted access to health information for research purposes. A sample copy of this agreement may be obtained from the Privacy Officer / Administrator or the Health Information Management Department.

6. To Avert a Serious Threat to Health or Safety:

We may disclose your protected health information to avoid a serious threat to your health or safety or to the health or safety of others. When such disclosure is necessary, information will only be released to those law enforcement agencies or individuals who have the ability or authority to prevent or lessen the threat of harm.

7. For Specific Government Functions:

We may disclose protected health information of military personnel and veterans, when requested by military command authorities, to authorized federal authorities for the purposes of intelligence, counterintelligence, and other national security activities (such as protection of the President), or to correctional institutions.

VI. Your Right Regarding Your Protected Health Information

You have the following rights concerning the use or disclosure of your protected health information that we create or that we may maintain on our premises:

1. To Request Restrictions on Uses and Disclosures of Your Protected Health Information:

You have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care or services. For example, you could request that we not disclose to family members or friends information about a medical treatment you received.

Should you wish a restriction placed on the use and disclosure of your protected health information, you must submit such request in writing. The address, and telephone number of the person to whom the request is to be submitted is listed on the last page of this document.

We are not required to agree to your restriction request. However, should we agree, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you.

2. The Right to Inspect and Copy Your Medical and Billing Records:

You have the right to inspect and copy your health information, such as your medical and billing records that we use to make decisions about your care and services. In order to inspect and/or copy your health information, you must submit a request to us in writing. If you request a copy of your medical information, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filing your requests. We will provide you with information concerning the cost of copying your health information prior to performing such service. The name, address, and telephone number of the person to whom you may make your request is listed on the last page of this document.

We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your health information, we will provide you with written notice of our reasons of the denial and your rights for requesting a review of our denial. If such review is granted or is required by law, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons for denial. We will abide by the reviewer’s decision concerning your inspection/copy requests.

3. The Right to Amend or Correct Your Health Information:

You have the right to request that your health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request. If we approve your request, we will make such amendments/corrections and notify those with a need to know of such amendments/corrections.

We may deny your request if:

a. Your request is not submitted in writing;
b. Your written request does not contain a reason to support your request;
c. The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
d. It is not a part of the health information kept by or for our facility;
e. It is not part of the information which you would be permitted to inspect and copy; and/or
f. The information is already accurate and complete.

If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial, and any written response you may have relative to the information and denial process appended to your health information.

The address, and telephone number of the person to whom you may file your request is listed on the last page of this document.

4. The Right to Request Confidential Communications:

You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we not send any health information about you to a family member’s address. We will agree to your request as long as it is reasonably easy for us to do so. You are not required to reveal nor will we ask the reason for your request.
The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document.

5. The Right to Request an Accounting of Disclosures of Protected Health Information:

You have the right to request that we provide you with a listing of when, to whom, for what purpose, and what content of your protected health information we have released over a specified period of time. This accounting will not include any disclosures we have made for the purposes of treatment, payment, or health care operations or information released to you, your family, or the facility directory, disclosures made for national security purposes, or any releases pursuant to your authorization.

Your request must be submitted to us in writing and must indicate the time period for which you wish the information (e.g., May 1, 2003 through August 31, 2005). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. We will respond to your request with sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be notified of such extension. However, in no case will such extension exceed thirty (30) days. The first accounting you request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the twelve (12) month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
The name, address, and telephone number of the person to whom you may file your request is listed on the last page of this document.

6. The Right to Receive a Paper Copy of This Notice:

You shall receive a copy of this notice at the time of addmission. You may request additional copy of this notice at anytime or you may obtain a copy of this information from our website. The name, address, and telephone number of the person from whom you may obtain a copy of this notice is listed on the last page of this document.

VII. How to File a Complaint About Our Privacy Practices

If you have reason to believe that we have violated your privacy rights, violated our privacy policies and procedures, or you disagree with a decision we made concerning access to your protected health information, etc., you have the right to file a complaint with us or the Secretary of the Department of Health and Human Services. Complaints may be filed without fear of retaliation in any form.
The address, and telephone number of the person to whom you may file your complaint is listed on the last page of this document.

NOTICE OF PRIVACY PRACTICES
Record of Acknowledgements

Name of Resident:__________________________________________________________ Date:__________________________________

We are committed to preserving the privacy and confidentiality of your health information whether created by us or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your health information. We are required by state and federal regulations to abide by the privacy practices described in the notice provided to you including any future revisions that we may make to the notice as may become necessary or as authorized by law.

Effective Date of This Privacy Notice
The effective date of this Privacy Notice is April 14, 2003.

Changes or Revisions to our Privacy Notice
We reserve the right to change our facility’s Privacy Notice at any time and to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future about you. Should we revise or change our Privacy Notice, we will post a copy of the new or revised notice on our information board. You may obtain a copy of the new/revised Privacy Notice from the Health Information Management Department or download a copy from our website.

[ ] Our Privacy Notice was revised on _________________________. [ ] No changes since the effective date listed above.

Privacy Notices, Information Restrictions, Record Amendments/Corrections, Disclosures of Information, Revoking an Authorization, Inspection and Copying of Records, Confidential Communications, Filing Complaints, Etc.

Should you have any questions concerning our facility’s privacy practices, obtaining copies of our privacy notice, requesting restrictions on the release of your information, revoking an authorization, amending or correcting your health information, obtaining a listing of the information we disclosed concerning your health information, requests to inspect or copy your medical information, requests that we communicate information about your health matters in a certain way, denial of access to your health information, filing complaints, or any other concerns you may have relative to our facility’s privacy practices, please contact:

Health Information Management Department or Privacy Officer
14900 El Camino Real / Atascadero, Ca 93422
Tel. (805) 466-0282
Fax. (805) 438-4405
CCCH@PACIFICCHRISTIANHOMES.ORG

YOU MAY ALSO FILE COMPLAINTS WITH:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
(202) 619-0257
Toll Free 1-877-696-6775

Acknowledgement

I certify that I received a copy of this facility’s Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanations provided to me and I am confident that the facility is committed to protecting my health information.
Date:__________________________
My Signature:___________________________________________________________________
My Printed Name:_______________________________________________________________
Date:__________________________
Signature of Witness:_____________________________________________________________

I certify that I am the authorized representative of _____________________________________________________________, and that I have received the Privacy Notice on behalf of this individual and that the facility provided me with an opportunity to review this document and ask questions to assist me in understanding his/her privacy rights. I am satisfied with the explanations provided to me and I am confident that the facility is committed to protecting health information.

Date:__________________________
Signature of Representative:________________________________________________________
Printed Name:___________________________________________________________________
Relationship to Individual:_________________________________________________________

Date:__________________________
Signature of Witness:_____________________________________________________________

Resident / Representative refuses to sign acknowledgement of Privacy Notice.

Reason for refusal to sign_____________________________________________________________________

A copy of this document must be provided to the person to whom the Privacy Notice was provided and a copy must be filed in the medical record.

Click here for downloadable version (.doc) and for print

Atascadero Christian Homes | 8455 Santa Rosa Road | Atascadero, CA 93422
ph (805) 466-0281 | fax (805) 466-9714