Version No.2 – December 8, 2003
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. Who Presents this Notice
This Notice describes the privacy practices of Olympia Medical Center (the “Hospital”), as well as the physician members of its workforce, the physician members of the medical staff, and allied health professionals who practice at the Hospital. The Hospital and the individual health care providers together are sometimes called "the Hospital and Health Professionals" in this Notice. While the Hospital and Health Professionals engage in many joint activities and provide services in a clinically integrated care setting, the Hospital and Health Professionals each are separate legal entities. This Notice applies to services furnished to you at Olympia Hospital and Olympia Hospital’s Ambulatory Care Center as a Hospital inpatient or outpatient or any other services provided to you in a Hospital-affiliated program involving the use or disclosure of your health information.
II. Privacy Obligations
The Hospital and Health Professionals are required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of legal duties and privacy practices with respect to your Protected Health Information. When the Hospital and Health Professionals use or disclose your Protected Health Information, the Hospital and Health Professionals are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure). Special privacy obligations, described in Section IV.D, apply to you if you are admitted to the Hospital’s psychiatric unit or chemical dependency treatment center.
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which are described in Section IV below, your written authorization must be obtained in order to use and/or disclose your PHI. However, the Hospital and Health Professionals do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures for Treatment, Payment and Health Care Operations.
Your PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), may be used to treat you, obtain payment for services provided to you and conduct “health care operations” as detailed below:
Treatment. Your PHI may be used and disclosed to provide treatment and other services to you--for example, to diagnose and treat your injury or illness. In addition, you may be contacted to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your PHI may also be disclosed to other providers involved in your treatment.
Payment. Your PHI may be used and disclosed to obtain payment for services provided to you--for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.
Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. For example, PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers. PHI may be disclosed to the Hospital Privacy Office and/or Director of Patient Relations in order to resolve any complaints you may have and ensure that you have a comfortable visit.
Your PHI also may be disclosed to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance. In addition, PHI may be shared with business associates who perform treatment, payment and health care operations services on behalf of the Hospital and Health Professionals.
B. Use or Disclosure for Directory of Individuals in the Hospital.
The Hospital may include your name, location in the Hospital, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory or are located in a specific ward, wing or unit the identification of which would reveal that you are receiving treatment for (1) mental health and developmental disabilities; (2) alcohol and drug abuse; (3) HIV/AIDS; (4) communicable disease(s); (5) genetic testing; (6) child abuse and neglect; (7) domestic and elder abuse or (8) sexual assault. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.
C. Disclosure to Relatives, Close Friends and Other Caregivers.
Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if (1) your agreement is obtained; (2) you do not object to the disclosure after being provided an opportunity to object; or (3) it can be reasonably inferred that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Hospital and Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative or a close personal friend, the Hospital and Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.
D. Public Health Activities.
Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
E. Victims of Abuse, Neglect or Domestic Violence.
Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.
F. Health Oversight Activities.
Your PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
G. Judicial and Administrative Proceedings.
Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
H. Law Enforcement Officials.
Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
Your PHI may be disclosed to a coroner or medical examiner as authorized by law.
J. Organ and Tissue Procurement.
Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
Your PHI may be disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.
L. Health or Safety.
Your PHI may be disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
M. Specialized Government Functions.
Your PHI may be disclosed to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
N. Workers’ Compensation.
Your PHI may be disclosed as authorized by and to the extent necessary to comply with California law relating to workers' compensation or other similar programs.
O. As Required by Law.
Your PHI may be disclosed when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization.
For any purpose other than the ones described above in Section III, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before PHI can be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. (However, marketing materials can be provided you in a face-to-face encounter without obtaining Your Marketing Authorization. The Hospital and Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization.) In addition, the Hospital and Health Professionals may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.
C. Uses and Disclosures of Your Highly Confidential Information.
In addition, federal and California law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment, and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic and elder abuse; or (9) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.
D. Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Chemical Dependency Treatment Center.
Information regarding your care in the Hospital and Health Professionals psychiatric unit or chemical dependency treatment center is subject to special protections under state and federal law. The terms of this Notice shall apply to your PHI unless otherwise described in this Section IV.D.
Your PHI will be disclosed to Hospital personnel and other qualified mental health professionals who have medical or psychological responsibility for your treatment, or in the course of a conservatorship proceeding. Your Authorization will be obtained prior to disclosing your PHI to other treatment providers who do not have medical or psychological responsibility for your care. To the extent necessary, your PHI will also be disclosed to obtain payment for services rendered to you, as for example, to your insurance company. On occasion, your PHI may be used for health care operations but, to the extent possible, your personally identifiable information will be removed.
Reasonable attempts will be made to notify your next of kin or any other person designated by you of your admittance for inpatient care, your release, transfer, serious illness or injury, unless you object to such disclosures. Your PHI will not be disclosed to your family members or any other person designated by you seeking information about your diagnosis, prognosis, medications and your progress unless your written Authorization is obtained. The Hospital and/or Health Professionals will not respond to other inquiries about your treatment and will not disclose information revealing that you are a patient of the psychiatric unit to other unauthorized individuals who call the Hospital to seek information without your written Authorization. If you are a minor or have a personal representative (such as a guardian or person authorized under a power of attorney), the Hospital and/or Health Professionals will consult with you prior to sharing information with such person. If you refuse to grant permission or are unable to grant permission, information may be shared with your personal representative only to the extent permitted or required by state law.
The Hospital and/or Health Professionals will comply with California law in reporting your PHI for public health activities or health oversight activities. If you disclose information related to child abuse or other types of actual or threatened abuse, such information may be reported to governmental authorities responsible to investigate such abuse. If you commit a crime on the premises, your PHI may be used to report the crime. To the extent possible, the Hospital and/or Health Professionals will notify you or seek a protective order prior to disclosing information to a judicial proceeding. Your PHI will not be used for marketing.
Chemical Dependency Treatment.
If you are a recipient of chemical dependency treatment, your PHI is protected by federal confidentiality laws (42 U.S.C. 290dd-3, 290ee-3 and 42 CFR Part 2) and California law. Violations of these laws is a crime and may be reported to appropriate authorities. Your PHI will be disclosed to Hospital personnel within the chemical dependency treatment program and certain organizations providing services to the program that have a need to know your PHI to perform their job duties or to medical personnel in the event of a medical emergency. Your authorization will be obtained prior to disclosing any PHI to obtain payment for services rendered to you, such as for example, to your insurance company. On occasion, your PHI may be used for health care operations but your identifying information will be removed. The Hospital and/or Health Professionals will not respond to inquiries about your treatment and will not disclose information revealing that you are a patient of the chemical dependency center to unauthorized individuals who call the Hospital to seek information. If you are twelve years of age or older, your PHI will not be disclosed to a family member, relative or any other person seeking information about your care without your written Authorization, except as permitted or required by state law.
If you are a minor twelve years of age or younger or have a personal representative (such as a guardian or person authorized under a power of attorney), you will be consulted prior to sharing information about your care. If you refuse to grant permission or are unable to grant permission, information may be shared with your personal representative only to the extent permitted or required by state law. The Hospital and Health Professionals will comply with federal and California law in reporting your PHI for public health activities or health oversight activities. If you disclose information related to child abuse, the Hospital and Health Professionals may be required to report such information to governmental authorities responsible to investigate such abuse. If you commit a crime on the premises your PHI may be used to report the crime. To the extent possible the Hospital and/or Health Professionals will notify you or seek a protective order prior to disclosing information to a judicial proceeding. Your PHI will not be used for marketing.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints.
If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Hospital Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Hospital Privacy Office will provide you with the correct address for the Director. The Hospital and Health Professionals will not retaliate against you if you file a complaint with the Hospital Privacy Office or the Director.
B. Right to Request Additional Restrictions.
You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, the Hospital and Health Professionals are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. A written response will be sent to you.
C. Right to Receive Confidential Communications.
You may request, and the Hospital and Health Professionals will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization.
You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that the Hospital and Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Privacy Office identified below. A form of Written Revocation is available upon request from the Privacy Office.
E. Right to Inspect and Copy Your Health Information.
You may request access to your medical record file and billing records maintained by the Hospital and Health Professionals in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records pertaining to health care services for which the minor can lawfully give consent and therefore for which the minor has the right to inspect or obtain copies of the record (i.e. abortion or mental health treatment); or the health care provider determines, in good faith, that access to the patient records requested by the representative would have a detrimental effect on the provider's professional relationship with the minor patient or on the minor's physical safety or psychological well-being. If you desire access to your records, please obtain a record request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. If you request copies, you will be charged the reasonable cost of copies in accordance with federal and state law. You also will be charged for the postage costs, if you request that the copies be mailed to you.
F. Right to Amend Your Records.
You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. Your request will be accommodated unless the Hospital and Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures.
Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged $0.25 per page of the accounting statement.
H. Right to Receive Paper Copy of this Notice.
Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date.
This Notice is effective on December 8, 2003.
B. Right to Change Terms of this Notice.
The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the Hospital and Health Professionals maintain, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted in waiting areas around the Hospital and on the Hospital’s Internet Site. You also may obtain any new notice by contacting the Hospital Privacy Office.
VII. Privacy Office
You may contact the Hospital Privacy Office at:
Olympia Medical Center
5900 W. Olympic Blvd., Los Angeles, CA 90019
Telephone Number: (310) 657-5900