JOINT NOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
If you have any questions about this notice, please contact the facility
Privacy Officer Marvin M. Cajina phone 626 350-7920, e-mail
WHO WILL FOLLOW THIS NOTICE
This notice describes our hospital's practices and that of:
- Any health care professional authorized to enter information into your
- All departments and units of the hospital.
- Any member of a volunteer group we allow to help you while you are in the hospital.
- All employees, staff and other hospital personnel.
- All Outpatient Therapy staff members
All these entities, sites and locations follow the terms of this notice.
In addition, these entities, sites and locations may share medical information
with each other for treatment, payment or health care operations purposes
described in this notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal.
We are committed to protecting medical information about you. We create
a record of the care and services you receive at the hospital. We need
this record to provide you with quality care and to comply with certain
legal requirements. This notice applies to all of the records of your
care generated by the hospital, whether made by hospital personnel or
your personal doctor. Your personal doctor may have different policies
or notices regarding the doctor's use and disclosure of your medical
information created in the doctor's office or clinic.
This notice will tell you about the ways in which we may use and disclose
medical information about you. We also describe your rights and certain
obligations we have regarding the use and disclosure of medical information.
We are required by law to:
- Make sure that medical information that identifies you is kept private
(with certain exceptions);
- Give you this notice of our legal duties and privacy practices with respect
to medical information about you; and
- Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose
medical information. For each category of uses or disclosures we will
explain what we mean and try to give some examples. Not every use or disclosure
in a category will be listed. However, all of the ways we are permitted
to use and disclose information will fall within one of the categories.1
DISCLOSURE AT YOUR REQUEST
We may disclose information when requested by you. This disclosure at
your request may require a written authorization by you.
We may use medical information about you to provide you with medical treatment
or services. We may disclose medical information about you to doctors,
nurses, technicians, health care students, or other hospital personnel
who are involved in taking care of you at the hospital. For example, a
doctor treating you for a broken leg may need to know if you have diabetes
because diabetes may slow the healing process. In addition, the doctor
may need to tell the dietitian if you have diabetes so that we can arrange
for appropriate meals. Different departments of the hospital also may
share medical information about you in order to coordinate the different
things you need, such as prescriptions, lab work and X-rays. We also may
disclose medical information about you to people outside the hospital
who may be involved in your medical care after you leave the hospital,
such as skilled nursing facilities, home health agencies, and physicians
or other practitioners. For example, we may give your physician access
to your health information to assist your physician in treating you.
We may use and disclose medical information about you so that the treatment
and services you receive at the hospital may be billed to and payment
may be collected from you, an insurance company or a third party. For
example, we may need to give information about surgery you received at
the hospital to your health plan so it will pay us or reimburse you for
the surgery. We may also tell your health plan about a treatment you are
going to receive to obtain prior approval or to determine whether your
plan will cover the treatment. We may also provide basic information about
you and your health plan, insurance company or other source of payment
to practitioners outside the hospital who are involved in your care, to
assist them in obtaining payment for services they provide to you.
FOR HEALTH CARE OPERATIONS
We may use and disclose medical information about you for health care
operations. These uses and disclosures are necessary to run the hospital
and make sure that all of our patients receive quality care. For example,
we may use medical information to review our treatment and services and
to evaluate the performance of our staff in caring for you. We may also
combine medical information about many hospital patients to decide what
additional services the hospital should offer, what services are not needed,
and whether certain new treatments are effective. We may also disclose
information to doctors, nurses, technicians, medical students, and other
hospital personnel for review and learning purposes. We may also combine
the medical information we have with medical information from other hospitals
to compare how we are doing and see where we can make improvements in
the care and services we offer. We may remove information that identifies
you from this set of medical information so others may use it to study
health care and health care delivery without learning who the specific
We may use information about you, or disclose such information to a foundation
related to the hospital, to contact you in an effort to raise money for
the hospital and its operations. You have the right to opt out of receiving
fundraising communications. If you receive a fundraising communication,
it will tell you how to opt out.
We may include certain limited information about you in the hospital directory
while you are a patient at the hospital. This information may include
your name, location in the hospital, your general condition (e.g., good,
fair, etc.) and your religious affiliation. Unless there is a specific
written request from you to the contrary, this directory information,
except for your religious affiliation, may also be released to people
who ask for you by name. Your religious affiliation may be given to a
member of the clergy, such as a priest or rabbi, even if they don't
ask for you by name. This information is released so your family, friends
and clergy can visit you in the hospital and generally know how you are doing.
MARKETING AND SALE
Most uses and disclosures of medical information for marketing purposes,
and disclosures that constitute a sale of medical information, require
TO INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE
We may release medical information about you to a friend or family member
who is involved in your medical care. We may also give information to
someone who helps pay for your care. Unless there is a specific written
request from you to the contrary, we may also tell your family or friends
your condition and that you are in the hospital.
In addition, we may disclose medical information about you to an organization
assisting in a disaster relief effort so that your family can be notified
about your condition, status and location. If you arrive at the emergency
department either unconscious or otherwise unable to communicate, we are
required to attempt to contact someone we believe can make health care
decisions for you (e.g., a family member or agent under a health care
power of attorney).
Under certain circumstances, we may use and disclose medical information
about you for research purposes. For example, a research project may involve
comparing the health and recovery of all patients who received one medication
to those who received another, for the same condition. All research projects,
however, are subject to a special approval process. This process evaluates
a proposed research project and its use of medical information, trying
to balance the research needs with patients' need for privacy of their
medical information. Before we use or disclose medical information for
research, the project will have been approved through this research approval
process, but we may, however, disclose medical information about you to
people preparing to conduct a research project, for example, to help them
look for patients with specific medical needs, as long as the medical
information they review does not leave the hospital.
AS REQUIRED BY LAW
We will disclose medical information about you when required to do so
by federal, state or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY
We may use and disclose medical information about you when necessary to
prevent a serious threat to your health and safety or the health and safety
of the public or another person. Any disclosure, however, would only be
to someone able to help prevent the threat.
ORGAN AND TISSUE DONATION
We may release medical information to organizations that handle organ
procurement or organ, eye or tissue transplantation or to an organ donation
bank, as necessary to facilitate organ or tissue donation and transplantation.
MILITARY AND VETERANS
If you are a member of the armed forces, we may release medical information
about you as required by military command authorities. We may also release
medical information about foreign military personnel to the appropriate
foreign military authority.
We may release medical information about you for workers' compensation
or similar programs. These programs provide benefits for work-related
injuries or illness.
PUBLIC HEALTH ACTIVITIES
We may disclose medical information about you for public health activities.
These activities generally include the following:
HEALTH OVERSIGHT ACTIVITIES
- To prevent or control disease, injury or disability;
- To report births and deaths;
- To report regarding the abuse or neglect of children, elders and dependent adults;
- To report reactions to medications or problems with products;
- To notify people of recalls of products they may be using;
- To notify a person who may have been exposed to a disease or may be at
risk for contracting or spreading a disease or condition;
- To notify the appropriate government authority if we believe a patient
has been the victim of abuse, neglect or domestic violence. We will only
make this disclosure if you agree or when required or authorized by law;
- To notify emergency response employees regarding possible exposure to HIV/AIDS,
to the extent necessary to comply with state and federal laws.
We may disclose medical information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary
for the government to monitor the health care system, government programs
and compliance with civil rights laws.
LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order.
We may also disclose medical information about you in response to a subpoena,
discovery request, or other lawful process by someone else involved in
the dispute, but only if efforts have been made to tell you about the
request (which may include written notice to you) or to obtain an order
protecting the information requested.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
- We may release medical information if asked to do so by a law enforcement
official:In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we
are unable to obtain the person's agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital; and
- In emergency circumstances to report a crime; the location of the crime
or victims; or the identity, description or location of the person who
committed the crime.
We may release medical information to a coroner or medical examiner. This
may be necessary, for example, to identify a deceased person or determine
the cause of death. We may also release medical information about patients
of the hospital to funeral directors as necessary to carry out their duties.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
We may release medical information about you to authorized federal officials
for intelligence, counterintelligence, and other national security activities
authorized by law.
PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS
We may disclose medical information about you to authorized federal officials
so they may provide protection to the President, other authorized persons
or foreign heads of state or conduct special investigations.
If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may disclose medical information about
you to the correctional institution or law enforcement official. This
disclosure would be necessary 1) for the institution to provide you with
health care; 2) to protect your health and safety or the health and safety
of others; or 3) for the safety and security of the correctional institution.
MULTIDISCIPLINARY PERSONNEL TEAMS
We may disclose health information to a multidisciplinary personnel team
relevant to the prevention, identification, management or treatment of
an abused child and the child's parents, or elder abuse and neglect.
SPECIAL CATEGORIES OF INFORMATION
In some circumstances, your health information may be subject to restrictions
that may limit or preclude some uses or disclosures described in this
notice. For example, there are special restrictions on the use or disclosure
of certain categories of information - e.g., tests for HIV or treatment
for mental health conditions or alcohol and drug abuse. Government health
benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary
information for purposes unrelated to the program.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain
RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy of medical information
that may be used to make decisions about your care. Usually, this includes
medical and billing records, but may not include some mental health information.
To inspect and obtain a copy of medical information that may be used to
make decisions about you, you must submit your request in writing to the
Release of Information Clerk, to obtain an authorization call (626) 350-7912.
If you request a copy of the information, we may charge a fee for the
costs of copying, mailing or other supplies associated with your request.
You may request an electronic copy of your records if available.
We may deny your request to inspect and obtain a copy in certain very
limited circumstances. If you are denied access to medical information,
you may request that the denial be reviewed. Another licensed health care
professional chosen by the hospital will review your request and the denial.
The person conducting the review will not be the person who denied your
request. We will comply with the outcome of the review.
RIGHT TO AMEND
If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right
to request an amendment for as long as the information is kept by or for
To request an amendment, your request must be made in writing and submitted
to [insert contact information]. In addition, you must provide a reason
that supports your request.
We may deny your request for an amendment if it is not in writing or does
not include a reason to support the request. In addition, we may deny
your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information
is no longer available to make the amendment;
- Is not part of the medical information kept by or for the hospital;
- Is not part of the information which you would be permitted to inspect
and copy; or
- Is accurate and complete.
Even if we deny your request for amendment, you have the right to submit
a written addendum, not to exceed 250 words, with respect to any item
or statement in your record you believe is incomplete or incorrect. If
you clearly indicate in writing that you want the addendum to be made
part of your medical record we will attach it to your records and include
it whenever we make a disclosure of the item or statement you believe
to be incomplete or incorrect.
RIGHT TO AN ACCOUNTING OF DISCLOSURES
You have the right to request an "accounting of disclosures."
This is a list of the disclosures we made of medical information about
you other than our own uses for treatment, payment and health care operations
(as those functions are described above), and with other exceptions pursuant
to the law.
To request this list or accounting of disclosures, you must submit your
request in writing to the facility Privacy Officer phone 626 350-7920
or e-mail firstname.lastname@example.org. Your request must state a time
period which may not be longer than six years and may not include dates
before April 14, 2003. Your request should indicate in what form you want
the list (for example, on paper or electronically). The first list you
request within a 12-month period will be free. For additional lists, we
may charge you for the costs of providing the list. 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.
In addition, we will notify you as required by law following a breach
of your unsecured protected health information.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request a restriction or limitation on the medical
information we use or disclose about you for treatment, payment or health
care operations. You also have the right to request a limit on the medical
information we disclose about you to someone who is involved in your care
or the payment for your care, like a family member or friend. For example,
you could ask that we not use or disclose information about a surgery you had.
We are not required to agree to your request, except to the extent that
you request us to restrict disclosure to a health plan or insurer for
payment or health care operations purposes if you, or someone else on
your behalf (other than the health plan or insurer), has paid for this
item or service out of pocket in full. Even if you request this special
restriction, we can disclose the information to a health plan or insurer
for purposes of treating you.
If we agree to another special restriction, we will comply with your request
unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the
facility Privacy Officer, Marvin Cajina phone (626) 350-7912 or e-mail
email@example.com. In your request, you must tell us 1) what
information you want to limit; 2) whether you want to limit our use, disclosure
or both; and 3) to whom you want the limits to apply, for example, disclosures
to your spouse.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS
You have the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example, you can
ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in
writing to the facility Privacy Officer 626 350-7912 or e-mail firstname.lastname@example.org.
We will not ask you the reason for your request. We will accommodate all
reasonable requests. Your request must specify how or where you wish to
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You may ask us to give
you a copy of this notice at any time. Even if you have agreed to receive
this notice electronically, you are still entitled to a paper copy of
You may obtain a copy of this notice at our website:
. To obtain a paper copy of this notice contact the facility Admitting
Department at 626 350-7952.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make
the revised or changed notice effective for medical information we already
have about you as well as any information we receive in the future. We
will post a copy of the current notice in the hospital. The notice will
contain the effective date on the first page, in the top right-hand corner.
In addition, each time you register at or are admitted to the hospital
for treatment or health care services as an inpatient or outpatient, we
will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a
complaint with the hospital or with the Secretary of the U.S. Department
of Health and Human Services. To file a complaint with the hospital, contact
Marvin Cajina 626-350-7920, Privacy Officer or e-mail email@example.com.
All complaints must be submitted in writing.
You will not be penalized 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 us will be made only with your written
permission. If you provide us permission to use or disclose medical information
about you, you may revoke that permission, in writing, at any time. If
you revoke your permission, this will stop any further use or disclosure
of your medical information for the purposes covered by your written authorization,
except if we have already acted in reliance on your permission. You understand
that we are unable to take back any disclosures we have already made with
your permission, and that we are required to retain our records of the
care that we provided to you.