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. Who We Are
This Notice describes the privacy practices of San Antonio Community
Hospital including members of its workforce, its Medical Staff physicians,
and allied health professionals who practice at the hospital. The hospital
and the individual health care providers together are sometimes called "us" or "we" in
this Notice. While we engage in many joint activities and provide services
in a clinically integrated care setting, we each are separate legal
entities. This Notice applies to services furnished to you at the hospital,
including but not limited to the Emergency Department, Outpatient Services
at Buildings 685 and 901, and Rancho San Antonio.
II. Our Privacy Obligations
We 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 our legal duties and privacy practices
with respect to your Protected Health Information. When we use or disclose
your Protected Health Information, we are required to abide by the
terms of this Notice (or other notice in effect at the time of the
use or disclosure).
III. Uses and Disclosures Without Your Consent
or Your Authorization
In certain situations, which we will describe in Section IV below,
we must obtain your written authorization in order to use and/or disclose
your PHI. However, we 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.
We may use and disclose PHI, but not your “Highly Confidential
Information” (defined in Section IV.C below), in order to treat
you, obtain payment for services provided to you and conduct our “health
care operations” as detailed below:
• Treatment. We use and disclose your PHI to provide treatment
and other services to you--for example, to diagnose and treat your
injury or illness. In addition, we may contact you to provide appointment
reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to you. We may also disclose
PHI to other providers involved in your treatment.
• Payment. We may use and disclose your PHI to obtain payment
for services that we provide 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. We may use and disclose your PHI for
our health care operations, which include internal administration and
planning and various activities that improve the quality and cost effectiveness
of the care that we deliver to you. For example, we may use PHI to
evaluate the quality and competence of our physicians, nurses and other
health care workers. We may disclose PHI to our Patient Relations Coordinator
in order to resolve any complaints you may have and ensure that you
have a comfortable visit with us.
We may also disclose PHI 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, we may share PHI with
our business associates who perform treatment, payment and health care
operations on our behalf.
B. Use or Disclosure for Directory of Individuals in San Antonio Community
Hospital. We may include your name, location in San Antonio Community
Hospital, general health condition and religious affiliation in a patient
directory without obtaining your authorization unless you object to
inclusion in the directory. 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. We
may use or disclose your PHI 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
we (1) obtain your agreement; (2) provide you with the opportunity
to object to the disclosure and you do not object; or (3) reasonably
infer 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, we may exercise our professional judgment
to determine whether a disclosure is in your best interest. If we disclose
information to a family member, other relative or a close personal
friend, we would disclose only information that we believe is directly
relevant to the person’s involvement with your health care or
payment related to your health care. We may also disclose your PHI
in order to notify (or assist in notifying) such persons of your location,
general condition or death.
D. Fundraising Communications. We may contact you to request a tax-deductible
contribution to support important activities of San Antonio Community
Hospital. In connection with any fundraising, we may disclose to
our fundraising staff demographic information about you (e.g., your
name, address and phone number) and dates on which we provided health
care to you, without your written authorization. If you wish to make
a tax-deductible contribution now or do not want to receive any fundraising
requests in the future, you may contact San Antonio Hospital Foundation
at (909) 920-4962.
E. Public Health Activities. We may disclose your PHI 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/or 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.
F. Victims of Abuse, Neglect or Domestic Violence. If we reasonably
believe you are a victim of abuse, neglect or domestic violence, we
may disclose your PHI 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.
G. Health Oversight Activities. We may disclose your PHI 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 (Medi-Cal).
H. Judicial and Administrative Proceedings. We may disclose your PHI
in the course of a judicial or administrative proceeding in response
to a legal order or other lawful process.
I. Law Enforcement Officials. We may disclose your PHI 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.
J. Decedents. We may disclose your PHI to a coroner or medical examiner
as authorized by law.
K. Organ and Tissue Procurement. We may disclose your PHI to organizations
that facilitate organ, eye or tissue procurement, banking or transplantation.
L. Research. We may use or disclose your PHI without your consent
or authorization if our Institutional Review Board approves a waiver
of authorization for disclosure.
M. Health or Safety. We may use or disclose your PHI to prevent or
lessen a serious and imminent threat to a person’s, or the public’s
health, or safety.
N. Specialized Government Functions. We may use and disclose your
PHI to units of the government with special functions, such as the
U.S. military or the U.S. Department of State, under certain circumstances.
O. Workers’ Compensation. We may disclose your PHI as authorized
by and to the extent necessary to comply with California law relating
to workers' compensation or other similar programs.
P. As required by law. We may use and disclose your PHI 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, we only may use or disclose
your PHI when you grant us your written authorization on our authorization
form (“Your Authorization”). For instance, you will need
to execute an authorization form before we can send your PHI to your
life insurance company or to the attorney representing the other party
in litigation in which you are involved.
B. Marketing. We must also obtain your written authorization (“Your
Marketing Authorization”) prior to using your PHI to send you
any marketing materials. (We can, however, provide you with marketing
materials in a face-to-face encounter without obtaining Your Marketing
Authorization. We are also permitted to give you a promotional gift
of nominal value, if we so choose, without obtaining Your Marketing
Authorization.) In addition, we 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 and treatment; (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/or neglect; (8)
is about domestic or elder abuse or (9) is about sexual assault. In
order for us to disclose your Highly Confidential Information for a
purpose other than those permitted by law, we must obtain your written
authorization. In accordance with federal and California law, there
are specific situations in which Highly Confidential Information may
be released without the patient's authorization:
1. Substance abuse information may be released in the following situations:
a. Program Personnel: Communication of information between or among
personnel who need such information to diagnose, treat, or refer
for treatment of alcohol or drug abuse, if the communications are
within a program or between a program and an entity that has direct
administrative control over the program.
b. Qualified Service Organizations: Communications between a program
and a qualified service organization of information needed by the organization
to provide services to the program (See 42 C.F.R. § 2.11 for definitions).
c. Crimes on Program Premises or Against Program Personnel: Communications
from program personnel to law enforcement officers that are directly
related to a patient's commission of a crime on program premises or
against program personnel or to a threat to commit such crime and are
limited to the circumstances of the incidents (See 42 C.F.R. § 2.12
(c)(5)).
d. Child Abuse Reports: Reports of suspected child abuse and/or neglect
under California law to the appropriate authorities (See 42 C.F.R. § 2.12
(c)(6)).
e. Veterans' Administration and Armed Forces: Certain exceptions apply
to records and information maintained by the Veterans' Administration
and Armed Forces (See 42 C.F.R. § 2.12 (c)(1)).
f. Medical Emergencies: Information may be disclosed to medical personnel
who need the information to treat a condition which poses an immediate
threat to the health of any individual and which requires immediate
medical intervention (See 42 C.F.R. § 2.51 (b) for other situations
involving medical emergencies).
g. Research Activities: Information may be disclosed for the purpose
of conducting scientific research if the program director determines
that the recipient of the patient-identifiable information is qualified
to conduct the research and has a research protocol under which the
patient-identifiable information will be maintained in accordance with
specified security requirements under the regulations. (See 42 C.F.R. § 2.16
for security requirements and § 2.52 for other restrictions related
to research activities).
h. Audit and Evaluation Activities: Information may be disclosed for
audit by an appropriate federal, state or local governmental agency
that provides financial assistance to the program or is authorized
by law to regulate its activities; a third party payer covering patients
in the program; a private person or entity that provides financial
assistance to the program; a peer review organization performing utilization
or quality control review; or an entity authorized to conduct a Medicare
or Medicaid (Medi-Cal) audit or evaluation (See 42 C.F.R. § 2.53
for certain restrictions involving audit and evaluation activities).
2. Reports of suspected child abuse or neglect and information contained
therein may be disclosed only to:
a. Law enforcement
b. Child welfare agency
c. Licensing agency (the state agency responsible for licensing the
agency in question).
3. Reports of elder and/or dependent adult abuse may be disclosed
only in the following situations:
a. Information relevant to the incident of elder or dependent adult
abuse may be given to an investigator from an adult protective services
agency, a local law enforcement agency, the Bureau of Medi-Cal fraud,
or investigators from the Department of Consumer Affairs, Division
of Investigation who are investigating the known or suspected case
of elder or dependent adult abuse.
b. Persons who are trained and qualified to serve on multidisciplinary
personnel teams may disclose to one another information and records
that are relevant to the prevention, identification, or treatment of
abuse of elderly or dependent adults.
c. The health care provider may disclose medical information covered
by the Confidentiality of Medical Information Act, Civil Code § 56,
et seq.
d. The health care provider may disclose mental health information
covered by Welfare and Institutions Code § 5328.
e. Information from elder abuse reports and investigations, except
for the identity of persons who have made reports.
f. Information pertaining to reports by health practitioners of persons
suffering from physical injuries inflicted by means of a firearm or
of persons suffering physical injury where the injury is a result of
assaultive or abusive conduct.
g. Information protected by the physician-patient or psychotherapist-patient
privileges.
4. HIV test results may be disclosed to the following persons without
the written authorization of the subject of the test:
a. To the subject of the test or the subject's legal representative,
conservator or to any person authorized to consent to the act.
b. To a test subject's provider of health care, as defined in Civil
Code § 56.05 (h).
c. To an agent or employee of the test subject's provider of health
care who provides direct patient care and treatment.
d. To a provider of health care who procures, processes, distributes
or uses a human body part donated pursuant to the Uniform Anatomical
Gift Act.
e. To the "designated officer" of an "emergency response
employee" (as those terms are used in the Ryan White Comprehensive
AIDS Resources Emergency Act of 1990).
f. To a procurement organization, a coroner, or a medical examiner
in conjunction with organ donation.
g. To a health care worker who has been exposed to the potentially
infectious materials of a patient provided that strict procedures for
testing and consent are followed.
h. To specified categories of persons, where the test has been performed
on a criminal defendant pursuant to Health and Safety Code §§ 121050
- 121065.
i. To an officer in charge of adult correctional or juvenile detention
facilities that an inmate or minor at such facility has been exposed
or infected by the AIDS virus or has an AIDS-related condition or other
communicable disease (See Health and Safety Code § 121070 for
information subject to disclosure).
5. Communicable diseases (See Title 17, California Code of Regulations § 2504
for a list of diseases that must be reported).
a. Health care facilities and clinics must establish administrative
procedures to assure that reports are made to the local health officer.
b. Where no health care provider is in attendance, any individual
having knowledge of a person who is suspected to have one of the diseases
listed in Title 17, California Code of Regulations § 2504 may
make a report to the local health officer for the jurisdiction in which
the patient resides.
c. Disease notifications must include, if known, the following information:
the name of the disease or condition; the date of onset; the date of
diagnosis; the name, address, telephone number, occupation, race/ethnic
group, social security number, sex, age, and the date of birth of the
patient; the date of death when applicable; and the name, address and
telephone number of the person making the report.
6. Release of mental health and developmental disability information
requires the written authorization of the patient only to the persons
listed below:
a. The patient's attorney, upon presentation of release of information
authorization signed by the patient (See Evidence Code § 1158
for authorization requirements). If the patient is unable to sign,
the facility may release records to the attorney, if the staff has
determined that the attorney does represent the interests of the patient.
b. A person designated by the patient, provided the professional in
charge of the patient gives approval; patient consent is not required
(See Welfare and Institutions Code §§ 5328.6 and 5328.7 for
additional requirements).
c. A person designated in writing by a patient's parent, guardian,
conservator, or guardian ad litem if the patient is a minor, ward or
conservatee; patient's consent is not required (See Welfare and Institutions
Code §§ 5328.6 and 5328.7 for additional requirements).
d. A professional person who does not have the medical or psychological
responsibility for the patient's care and who is not employed by the
facility that maintains the record (See Welfare and Institutions Code §§ 5328.6
and 5328.7 for additional requirements).
e. A life or disability insurer provided the patient designates the
insurer in writing.
f. A qualified physician or psychiatrist who represents an employer
to which the patient has applied for employment unless the physician
or administrative officer responsible for the care of the patient deems
the release contrary to the best interests of the patient (See Welfare
and Institutions Code § 5328.9 for additional requirements).
g. A probation officer charged with the evaluation of a person after
his or her conviction of a crime if the person has been previously
confined in, or otherwise treated by, a facility (See Welfare and Institutions
Code § 5328 (k) for additional requirements).
h. An applicant for, or recipient of, services from the state Department
of Developmental Services (or the person's authorized representative)
for the purpose of appealing an adverse eligibility or benefits decision
(See Welfare and Institutions Code §§ 4726 - 4730 for additional
requirements).
i. A county patients' rights advocate upon presentation of written
authorization, signed by the patient who is the advocate's "client" or
by the "client's" guardian ad litem (See Welfare and Institutions
Code §§ 5328 (m) and 5546 for additional requirements and
definitions).
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 we have violated your
privacy rights or disagree with a decision that we made about access
to your PHI, you may contact our 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 Privacy
Office will provide you with the correct address for the Director.
We will not retaliate against you if you file a complaint with us or
the Director.
B. Right to Request Additional Restrictions. You may request restrictions
on our 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 we will consider
all requests for additional restrictions carefully, we are not required
to agree to a requested restriction. If you wish to request additional
restrictions, please obtain a request form and submit the completed
form to the Privacy Office. We will send you a written response.
C. Right to Receive Confidential Communications. You may request,
and we 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 we have taken action in reliance upon it, by delivering
a written revocation statement to the 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
us in order to inspect and request copies of the records. Under limited
circumstances, we may deny you access to a portion of your records.
If you desire access to your records, please obtain a record request
form from Health Information Management
and submit
the completed form to Health Information Management
. If you request
copies, we will charge you $0.25 for each page ($0.50 per page for
records copied from microfilm) and any reasonable clerical costs incurred.
This will not exceed actual costs, incurred by a health care provider
in providing copies of x-rays or tracings derived from electrocardiography,
electroencephalography or electromyography. We will also charge you
for our postage costs, if you request that we mail the copies to you.
Note: 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; 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.
F. Right to Amend Your Records. You have the right to request that
we amend Protected Health Information maintained in your medical record
file or billing records. If you desire to amend your records, please
obtain an amendment request form from the Privacy Office and submit
the completed form to the Privacy Office. We will comply with your
request unless we 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 by
us 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, we will charge you
$5.00 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.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of
this Notice at any time. If we change this Notice, we may make the
new notice terms effective for all Protected Health Information that
we maintain, including any information created or received prior to
issuing the new notice. If we change this Notice, we will post the
new notice in waiting areas around San Antonio Community Hospital and
on our Internet site at www.sach.org. You also may obtain any new notice
by contacting the Privacy Office.
VII. Privacy Office
You may contact the Privacy Office at:
Privacy Office
San Antonio Community Hospital
999 San Bernardino Road
Upland, CA 91786
Telephone Number: (909) 579-6991 or
E-mail: PrivacyOffice@SACH.org
