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:
describes our facilities practices and that of :
Any health care professional authorized to enter information into
your medical record.
All departments of the facility.
Any volunteer we allow to help you while you are in the facility.
All employees, staff and other personnel.
All entities that are located on the facility campus will follow the
terms of this notice. In addition the entities located on the facility campus may share medical information with each other
for treatment, payment or health care operations purposes described in this notice.
WE HAVE A LEGAL DUTY TO SAFEGUARD
YOUR PROTECTED HEALTH INFORMATION (PHI)
We are legally required to protect the privacy of your health information.
We call this information “protected health information,” or “PHI” for short and it includes information
that can be used to identify you that we’ve created or received about your past, present, or future health or condition,
the provision of health care to you, or the payment for this health care. We must provide you with this notice about
our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use
or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required
to follow the privacy practices that are described in this notice.
However, we reserve the right to change the
terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make
an important change to our policies, we will promptly change this notice and post a new notice in the facility lobby. You
can also request a copy of this notice from the admission clerk.
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH
We use and disclose health information for many different reasons. We describe the different
categories of our uses and disclosures below and give you some examples of each category.
1. For Treatment
– We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you
with health care services or are involved in your care. For example, if you are being treated for a knee injury, we may disclose
your PHI to the physical therapy department in order to coordinate your care.
2. To obtain Payment for Treatment –
We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For
example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care
services we provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing
companies, and others that process our health care claims.
3. For Health Care Operations – We may disclose your
PHI in order to operate this hospital. For example, we may use your PHI in order to evaluate the quality of health care services
that you received. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure
we are complying with the laws that affect us.
4. When a disclosure is required by federal, state, or local law, judicial
or administrative proceedings, or law enforcement – For example, we make disclosures when a law requires that we report
information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when
dealing with a gunshot and other wounds; or when ordered in a judicial or administrative proceedings.
5. Lawsuits and
Disputes – If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to
a court or other administrative order. We may also disclose medical information about you in response to a subpoena, discovery
request, or other lawful order from the court.
6. Coroners, Medical Examiners and Funeral Directors – 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 facility to funeral directors
as necessary to carry out their duties.
7. For Public Health Activities – For example, we report information about
births, deaths, and various diseases to government officials in charge of collecting that information, and we provide coroners,
medical examiners, and funeral directors necessary information relating to an individual’s death.
8. For Health
Oversight Activities – For example, we will provide PHI to assist the government when it conducts an investigation or
inspection of a health care provider or organization.
9. Inmates – If you are an inmate of a correctional institution
or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement
official. This release would be necessary:
a. For the institution to provide you with health care.
b. To protect
your health and safety or the health and safety of others.
c. For the safety and security of the correctional institution.
10. For Purposes of Organ Donation – We may notify organ procurement organizations to assist them in organ, eye, or
tissue donation and transplants.
11. For Research Purposes – In certain circumstances, we may provide PHI in order
to conduct medical research. Before we use or disclose medical information for research, the project will have been approved
through a research approval process. We will ask for your permission if the research will have access to your name, address
or other information that reveals who you are.
12. To Avoid Harm – In order to avoid a serious threat to the health
or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen
13. For Specific Government Functions – We may disclose PHI of military personnel and veterans in certain
situations. And we may disclose PHI for national security purposes, such as protecting the President of the United States
or conducting intelligence operations.
14. For Workers’ Compensation Purposes – We may provide PHI in order
to comply with workers’ compensation laws.
15. Appointment Reminders and Health-Related Benefits or Services –
We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care
services or benefits we offer.
16. Two Uses and Disclosures Require You to Have the Opportunity to Object
Directives – We may include your name, location in this facility, and religious affiliation, in our patient directory
for use by visitors who ask for you by name, unless you object in whole or in part. The opportunity to consent may be obtained
retroactively in emergency situations.
b. Disclosures to Family, Friends, or Other – We may provide your PHI to
a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless
you object in whole or part. The opportunity to consent may be obtained retroactively in emergency situations.
from Clergy – We may provide your name, location in the facility, and religion to clergy members, unless you object
in whole or part.
WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect
to your PHI:
A. The Right to Request Limits on Uses and Disclosures of Your PHI – You have the right to ask
that we limit how we use and disclose your PHI. We will consider your written request but are not legally required to accept
it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may
not limit the uses and disclosures that we are legally required or allowed to make.
B. The Right to Choose How We Send
PHI to You – You have the right to ask that we send information to you to an alternate address (for example, sending
information to your work address rather than your home address) or by alternate means. We must agree to your written request
as long as we can easily provide it in the format you requested.
C. The Right to See and Get Copies of Your PHI –
In most cases, you have the right to look at or get copies of the PHI we have, but you must make the request in writing. If
we do not have your PHI but we know who does, we will tell you how to get it. We will respond to you within 5 working days
after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing,
our reasons for denial and explain your right to have the denial reviewed.
D. The Right to Get a List of the Disclosures
We Have Made – You have the right to get a list of instances in which we have disclosed your PHI. The list will not
include uses or disclosures used for treatment, payment, or health care operations, or authorization releases made by you.
The list also will not include uses and disclosures made for national security purposes, to corrections or law enforcement
personnel, or before April 14, 2003.
We will respond within 60 days of receiving your request. The list we will give
you will include disclosures made after April 14, 2003 for a period no longer than six years unless you request a shorter
time. The list will include the date of disclosure, to whom PHI was disclosed (including their address, if known), a description
of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you
make more than one request in the same year, a reasonable fee may be requested once each calendar year.
E. The Right
to Correct or Update Your PHI – If you believe there is a mistake in your PHI or that a piece of important information
is missing, you have the right to request that we correct the existing information or add the missing information. You must
provide the request and your reason for the request in writing. We will respond to you within 60 days of receiving your request.
We may deny your request in writing if the PHI is (i) correct and complete (ii) not created by use, (iii) not allowed to be
disclosed, or (iv) not part of your records. Our written denial will state the reasons for the denial and explain your right
to file one. You have the right to request that your request and our denial be attached to all future disclosures
of your PHI. If we approve your request, we will make the change to your PHI, notify you that the change was made, and notify
others that need to know about the change in your PHI.
HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to
your PHI, you may file a complaint with the Privacy Officer. You also may send a written complaint to the Office for Civil
Rights, U.S. Department of Health and Human Services, 50 United Nations Plaza – Room 322, San Francisco, CA 94103. We
will take no retaliatory action against you if you file a complaint about our privacy practices.
PERSON TO CONTACT
FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you have any questions about this
notice or any questions about our privacy practices, or would like to know how to file a complaint with the Secretary of the
Department of Health and Human Services, please contact the Privacy Officer, Modoc Medical Center, 228 McDowell St., Alturas,
CA 96101, phone number (530) 233-7032.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures
of PHI 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 your PHI, you may revoke that permission, in writing, at any time. If you revoke your permission,
we will no longer use or disclose your PHI for the reasons covered by your written authorization. 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.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper
copy of this notice at any time. You may obtain a copy of this notice from the Admitting Department or, if it is after hours,
the Nursing Department.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect April 14, 2003.