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Health Insurance Portability and Accountability Act of 1996 (HIPPA)
NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003
PACIFIC CLINICAL RESEARCH MANAGEMENT GROUP LLC
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.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly.
We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. The protected health information (medical information) constitutes information created or received by us that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. This notice describes how we may use and disclose your protected health information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer at 909-920-3000.
Please note that if you qualify for and consent to participate in a clinical research study, the health information collected for that study will be governed by study-specific Authorization pertaining to your health information. Pacific Clinical Research Management Group LLC’s privacy practices described in this notice apply only to the protected health information that is not included in any study record, and that is not otherwise subject to the study-specific authorization.
USES AND DISCLOSURES OF INFORMATION
The law permits us to use or disclose your health information for many different reasons. Some of the uses or disclosures will require your prior written authorizations; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.
Certain Uses and Disclosures That Do Not Require Your Prior Written Consent. We may use and disclose your health information without your consent or authorization for the following reasons.
Treatment: We may use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians, psychiatrists, psychologists, or health care providers who will provide you with health care services or are otherwise involved in your care. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured.
Payment: We may use and disclose medical information about you to obtain payment for the services we provide. For example, we may give the paying party the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
Health care operations: We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews; legal services and audits, including fraud and abuse detection and compliance programs; and business planning and management.
We may also share your medical information with our “business associates,” who perform services on our behalf. For example, we may contract with a company to do data analysis, quality assurance, practice management consulting, or other services. We have a written contract with each of these business associates that contain terms requiring them to protect the confidentiality and security of your medical information. Although federal law does not protect health information which is disclosed to someone other than another healthcare provider, health plan or healthcare clearinghouse, under California law all recipients of health care information are prohibited from redisclosing it except as specifically required or permitted by law.
We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you when they request this information to help them with their quality assessment and improvement activities, their efforts to improve health or reduce health care costs, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. Appointment reminders: We may use and disclose medical information to contact you and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.
Sign in sheet: We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.
Required by law: As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
Public health: We may, and are sometimes required by law to, disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
Abuse, neglect, or domestic violence: As required or permitted by law, we may disclose health information about you to public authorities to report suspected child, elder or dependent adult abuse or neglect or domestic violence. If such a report is optional, we will use our professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly that we have made such a disclosure, unless in our best professional judgment we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
Health oversight activities: We may, and are sometimes required by law to, disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by federal and California law.
Judicial and administrative proceedings: We may, and are sometimes required by law to, disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
Law enforcement: We may, and are sometimes required by law to, disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, or grand jury subpoena, and other law enforcement purposes.
Coroners, funeral directors, and for organ donation: We may, and are sometimes required by law to, disclose your health information to a coroner or medical examiner in connection with their investigations of a death. In addition, we may disclose health information to a funeral director to enable the funeral director to carry out his or her duties. It may also be disclosed for the purpose of cadaveric organ, eye or tissue donation.
Public safety: We may, and are sometimes required by law to, disclose your protected health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Specialized government functions: We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody. Workers’ compensation: We may disclose your health information to comply with workers’ compensation laws. Change of ownership: In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request copies of your health information to be transferred to another physician or medical group.
Research: We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board in compliance with governing law.
Marketing: We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services that may be of interest to you, or to provide you with small gifts. We may also encourage you to purchase a product or service when we see you. If you are currently an enrollee of a health plan, we may receive payment for communications to you in conjunction with our provision, coordination, or management of your health care and related services, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care, but only to the extent these communications describe: 1) a provider’s participation in the health plan’s network, 2) the extent of your covered benefits, or 3) the availability of more cost-effective pharmaceuticals.
We will not accept any payment for other marketing communications without your prior written authorization unless you have a chronic and seriously debilitating or life-threatening condition and we are making the communication in conjunction with our provision, coordination, or management of your health care and related services, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care. If we make these types of communications to you while you have a chronic and seriously debilitating or life-threatening condition, we will tell you who is paying us, and we will also tell you how to stop these communications if you prefer not to receive them. We will not otherwise use or disclose your medical information for marketing purposes without your written authorization, and we will disclose whether we receive any payments for any marketing activity you authorize.
Other disclosures: For example, your consent is not required if you need emergency treatment provided that we attempt to obtain your consent after treatment is rendered. In the event that we try to obtain your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your health information.
Certain Permitted Uses and Disclosures That Require You to Have the Opportunity to Object.
Notification and communication to family, friends, or others: We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care or responsible for the payment of your care about your location, your general condition or in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care if the disclosure is directly relevant to the person’s involvement in your care or payment related to your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. Retroactive consent may be obtained in emergency situations. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
Other Uses and Disclosures That Require Your Prior Written Authorization. Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
Psychotherapy notes may be disclosed by a therapist/doctor only after you have given written authorization to do so. (Limited exceptions exist; e.g., in order for your therapist/doctor to attempt to prevent harm to yourself or others, and to report child abuse or neglect). Moreover, we may use or disclose such notes for treatment, payment, or health care operations as follows: (1) use by our practice for your treatment; (2) use for training physicians or other mental health professionals as authorized by applicable regulations; (3) use or disclosure in defense of a legal action brought by you or by someone on your behalf; and (4) use or disclosures as required by law, or as authorized by law to enable health oversight agencies to oversee the originator of the psychotherapy notes.
You cannot be required to authorize the release of your psychotherapy notes in order to obtain health insurance benefits for your treatment or enroll in a health plan. Psychotherapy notes are among the records that we may decline to allow you to review or copy (see the discussion of your rights below). If you have any questions, please feel free to discuss this subject with your therapist/doctor.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Under the law, you have certain rights regarding the health information that we collect and maintain about you. This includes:
Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision.
Right to Request Confidential Communications: You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.
Right to Inspect and Copy: You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We may charge a reasonable fee, as allowed by California and federal law. We may deny your request under limited circumstances. If we deny your request to access your child’s records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your mental health records or psychotherapy notes, you will have the right to have them transferred to another mental health professional.
Right to Amend or Supplement: You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice’s denial and how you can disagree with that denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, if the information constitutes psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.
Right to an Accounting of Disclosures: You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in the paragraphs above regarding treatment, payment, health care operations, specialized government functions, and notification and communication with family, friends, and others, as set forth in the section entitled “Certain Uses and Disclosures That Do Not Require Your Prior Written Consent” of this Notice of Privacy Practices, or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
Right to Paper Copy: You have the right to a paper copy of this Notice of Privacy Practices. If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, please speak with our Privacy Officer at 909-920-3000.
CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted online and in our reception area, and a copy will be available at each appointment.
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer at 909-920-3000.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Office for Civil Rights
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
EFFECTIVE DATE: April 14, 2003
1317 W. Foothill Blvd., Suite #140
Upland, CA 91786