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NORTHEASTERN
RURAL HEALTH CLINICS 1850
SPRING RIDGE DRIVE, SUSANVILLE, CA 96130 NOTICE
OF PRIVACY PRACTICES Effective
Date: June 20, 2005 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. If you have any questions
about this notice, please contact Cindy Azevedo, Clinic Manager at
(530) 257-5563. WHO
WILL FOLLOW THIS NOTICE
This notice describes our
health center practices and that of: •
any health care professional authorized to enter information into
your medical chart •
all departments and units of the health center •
any member of a volunteer group we allow to help you while you
are in the health center •
all employees, staff and other health center personnel Northeastern Health Center,
Doyle Family Practice, Westwood Family Practice and Northeastern Rural
Health Clinic’s WIC Program. 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
health center. 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 health
center, whether made by health center personnel or your personal doctor.
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. For
Treatment - 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, medical students, or other healthcare personnel who are
involved in taking care of you at the health center. For
Payment - We may use and disclose medical information about you so
that the treatment and services you receive at the health center may be
billed to and payment may be collected from you, an insurance company or
a third party. We may 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. 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 health
center 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 health center patients to decide
what additional services the health center 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 health center personnel for review and
learning purposes. We may
also combine the medical information we have with medical information
from other health centers 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 patients are. Appointment
Reminders - We may use
and disclose medical information to contact you as a reminder that you
have an appointment for treatment or medical care at the health center. Treatment
Alternatives - We may use and disclose medical information to tell
you about or recommend possible treatment options or alternatives that
may be of interest to you. Health-Related
Products and Services - We
may use and disclose medical information to tell you about our
health-related products or services that may be of interest to you. 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. Research
- Under certain circumstances, we may use and disclose medical
information about you for research purposes.
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, so long as the medical
information they review does not leave the health center.
We will almost always ask for your specific permission if the
researcher will have access to your name, address or other information
that reveals who you are, or will be involved in your care at the health
center. 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. SPECIAL
SITUATIONS 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. Workers’
Compensation - 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 Risks - We may
disclose medical information about you for public health activities.
These activities generally include the following: •
to prevent or control disease, injury or disability; •
to report births and deaths; •
to report 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) Health Oversight
Activities - 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. Law
Enforcement - 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. 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. Inmates
- If you are an inmate of a correctional institution or under the
custody of a law enforcement official, we may release medical
information about you to the correctional institution or law enforcement
official. This release
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. YOUR
RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following
rights regarding medical information we maintain about you: Right
to Inspect and Copy - You have the right to inspect and copy 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 copy medical information that may be used to make
decisions about you, you must submit your request in writing to Cindy
Azevedo, Clinic Manager at 1850 Spring Ridge Drive, Susanville,
CA 96130. 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.
We may deny your request to inspect and 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 health center 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 the health center.
To request an amendment, your request must be made in writing and
submitted to Cindy Azevedo, Clinic Manager at 1850 Spring Ridge
Drive, Susanville, CA 96130.
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 health
center •
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
expectations pursuant to the law. To
request this list or accounting of disclosures, you must submit your
request in writing to Cindy Azevedo, Clinic Manager .
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, 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. 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.
If we do agree, 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
Cindy Azevedo, Clinic Manager .
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 Cindy
Azevedo, Clinic Manager .
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 be contacted. 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 this notice.
You may obtain a copy of this notice at our website: www.northeasternhealth.org.
To obtain a paper copy of this notice, write to: Cindy
Azevedo, Clinic Manager . 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 health center.
The notice will contain on the first page, in the top right-hand
corner, the effective date. In
addition, each time you register for treatment or health care services
we will offer you a copy of the current notice in effect. COMPLAINTS If you believe your privacy
rights have been violated, you may file a complaint with the health
center or with the Secretary of the Department of Health and Human
Services. To file a
complaint with the health center, contact Cindy Azevedo, Clinic
Manager (530) 257-5563.
All complaints must be submitted in writing. 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. |