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.
THIS NOTICE ALSO DESCRIBES HOW FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED.
YOUR FINANCIAL INFORMATION
Wilshire Hospice (the “Agency” or “us” or “we”) collects and uses several types of financial information to carry out health insurance activities. This includes information that you give us on applications or other forms, such as your name, address, age, and dependents. We keep records about your business with our affiliates, others, or us, including insurance coverage, premiums, and payment history. We also keep any information we may get from a consumer-reporting group.
We use physical, technical, and procedural methods to protect your private information. We share it only with our employees, affiliates or others who need it to provide service, to do insurance business, or for other legally allowed or required purposes.
USE AND DISCLOSURE OF MEDICAL INFORMATION
The Agency may use your health information, information that constitutes protected health information (as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996), for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Agency has established policies to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH, AND PURPOSES FOR WHICH, YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment. The Agency may use your health information to provide treatment to you. For example, we collect health information from you in the course of providing treatment to you and we may review such health information periodically to assess the course of treatment we are providing; or, we may use your health information that we obtain in the course of treating you and may make available to other providers to assist them in providing care to you.
To Obtain Payment. The Agency may include your health information in invoices to collect payment from third parties for the care you receive from the Agency. For example, the Agency may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or the Agency. The Agency also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for services and the services that will be provided to you. In addition, a group health plan (or a health insurance issuer or HMO with respect to a group health plan) may disclose protected health information to the sponsor of the plan, all in accordance with 45 CFR § 164.504(f), or
To Conduct Health Care Operations. The Agency may use and disclose health information for its own operations in order to facilitate the function of the Agency and as necessary to provide quality services. Health care operations includes such activities as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol development, case management and care coordination.
- Contacting health care providers and patients with information about treatment alternatives and other related functions that do not include treatment.
- Professional review and performance evaluation.
- Training programs including those in which students, trainees or practitioners in health care learn under supervision.
- Training of non-health care professionals.
- Accreditation, certification, licensing or credentialing activities.
- Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
- Business planning and development including cost management and planning related analyses and formulary development.
- Business management and general administrative activities of the Agency.
- Fundraising for the benefit of the Agency.
For Fundraising Activities: The Agency may use information about you including your name, address, phone number and the dates you received care at the Agency in order to contact you or your family to raise money for the organization. The Agency may also release this information to a related Agency foundation. If you do not want the Agency to contact you or your family, notify the Administrator or Agency Designee at (805) 782-8608 and indicate that you do not wish to be contacted or you may return fundraising material indicating you wish to be removed from the mailing list.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED:
When Legally Required.
The Agency will disclose your health information when it is required to do so by any Federal, State or local law.
When There Are Risks to Public Health.
The Agency may disclose your health information for public activities and purposes in order to:
- Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
- Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
- Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
- Notify an employer about an individual who is a member of the workforce, but only as legally required.
To Report Abuse, Neglect Or Domestic Violence. The Agency is allowed to notify government authorities if the Agency believes a patient is the victim of abuse, neglect or domestic violence. The Agency will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities. The Agency may disclose your health information to a health oversight organization for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. The Agency, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.
In Connection With Judicial And Administrative Proceedings. The Agency may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, but only as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.
For Law Enforcement Purposes. As permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:
- As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
- For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
- Under certain limited circumstances, when you are the victim of a crime.
- To a law enforcement official if the Agency has a suspicion that your death was the result of criminal conduct including criminal conduct at the Agency.
- In an emergency in order to report a crime.
In the Event of A Serious Threat To Health Or Safety. The Agency may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Agency, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Specified Government Functions. In certain circumstances, the Federal regulations authorize the Agency to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker's Compensation. The Agency may release your health information for worker's compensation or similar programs.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than as stated above, the Agency will not disclose your health information except with your written authorization. If you (or your representative) authorize the Agency to use or disclose your health information, you (or your representative) may revoke that authorization in writing at any time. Without regard to the foregoing, the Agency may not disclose, without your express written authorization: (i) health information that constitutes psychotherapy notes except in limited circumstances; (ii) health information for marketing purposes except in limited circumstances; or (iii) health information as part of a sale of health information.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights regarding your health information that the Agency maintains:
- Right to request restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Agency’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Agency is not required to agree to your request unless the disclosure is for the purpose of obtaining payment or carrying out health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which the individual, or a person other than the health plan on behalf of the individual, has paid the covered entity in full. If you wish to make a request for restrictions, please contact the Privacy Officer or Agency Designee at (805) 782-8608.
- Right to receive confidential communications. You have the right to request that the Agency communicate with you in a certain way. For example, you may ask that the Agency only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Privacy Officer or Agency Designee at (805) 782-8608.
The Agency will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
- Right to inspect and copy your health information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to the Privacy Officer or Agency Designee at (805) 782-8608. If you request a copy of your health information, the Agency may charge a reasonable fee for copying and assembling costs associated with your request.
- Right to amend health care information. You or your representative have the right to request that the Agency amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by the Agency. A request for an amendment of records must be made in writing to the Privacy Officer or Agency Designee at c/o Wilshire Hospice 277 South Street, Suite R, San Luis Obispo, CA 93401. The Agency may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by the Agency, if the records you are requesting are not part of the Agency‘s records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of the Agency, the records containing your health information are accurate and complete.
- Right to an accounting. You or your representative have the right to request an accounting of disclosures of your health information made by the Agency for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to the Privacy Officer or Agency Designee c/o Wilshire Hospice 277 South Street, Suite R, San Luis Obispo, CA 93401. The request should specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. The Agency would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
- Right to a paper copy of this notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact to the Privacy Officer or Agency Designee at c/o Wilshire Hospice 277 South Street, Suite R, San Luis Obispo, CA 93401. The patient or a patient’s representative may also obtain a copy of the current version of the Agency’s Notice of Privacy Practices at its website, www.wilshirehospicecc.org
DUTIES OF THE AGENCY
The Agency is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices and to notify you following a breach of unsecured health information. The Agency is required to abide by the terms of this Notice currently in effect. The Agency reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If the Agency changes its Notice, the Agency will post a copy of the revised Notice on the agency website at www.wilshirehospicecc.org which will be available to you or your appointed representative. You or your personal representative have the right to express complaints to the Agency and to the Secretary of DHHS if you or your representative believe that your privacy rights have been violated. Any complaints to the Agency should be made in writing to the Privacy Officer or Agency Designee c/o Wilshire Hospice, 277 South Street, Suite R, San Luis Obispo, CA 93401. The Agency encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
The Agency has designated the Administrator as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 277 South Street, Suite R, San Luis Obispo, CA 93401, (805) 782-8608.
This Notice is effective April 14, 2003.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT
277 South Street, Suite R
San Luis Obispo, CA 93401