THIS NOTICE DESCRIBES HOW THE ASHLAND FREE MEDICAL CLINIC WILL USE AND DISCLOSE MEDICAL, DENTAL AND MENTAL HEALTH INFORMATION, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
WE WILL DO EVERYTHING REQUIRED BY LAW TO PROTECT IT. In this notice we use the terms "we," "us," and "our" and “AFMC” to describe Ashland Free Medical Clinic. We use “PHI” to refer to Protected Health Information.
I. WHAT IS "PROTECTED HEALTH INFORMATION?"
Your protected health information (PHI) is health information that contains identifiers, such as your name, Social Security number, or other information that reveals who you are. For example, your medical record is PHI because it includes your name and other identifiers.
II. ABOUT OUR RESPONSIBILITY TO PROTECT YOUR PHI
By law, we must
1. protect the privacy of your PHI,
2. tell you about your rights and our legal duties with respect to your PHI, and
3. tell you about our privacy practices and follow our notice currently in effect.
We take these responsibilities seriously and we will take appropriate steps to safeguard the privacy of your PHI. In the course of providing health care, we collect various types of PHI from patients and other sources, including other health care providers. The medical information may be used, for example, to provide health care services, measure performance (utilization review), apply for grants, review the competence or qualifications of health care professionals, and fulfill legal and regulatory requirements.
The types of PHI that we collect and maintain about patients include:
• Hospital, medical, mental health and substance abuse patient records, laboratory results, X-ray reports, pharmacy records and appointment records;
• Information from patients, for example, through surveys, applications and other forms, and
• Information about your relationship with AFMC such as: medical services received, appointment history.
III. YOUR RIGHTS REGARDING YOUR PHI
This section tells you about your rights regarding your PHI, for example, your medical and billing records. It also describes how you can exercise these rights.
Your right to see and receive copies of your PHI
In general, you have a right to see and receive copies of your PHI in designated record sets such as your medical record or billing records. If you would like to see or receive a copy of such a record, please write us. After we receive your written request, we will let you know when and how you can see or obtain a copy of your record. If you agree, we will give you a summary or explanation of your PHI instead of providing copies. We may charge you a fee for the copies, summary, or explanation. If we don't have the record you asked for but we know who does, we will tell you who to contact to request it. In limited situations, we may deny some or all of your request to see or receive copies of your records, but if we do, we will tell you why in writing and explain your right, if any, to have our denial reviewed.
Your right to choose how we send PHI to you
You may ask us to send your PHI to you at a different address (for example, your work address) or by different means (for example, fax instead of regular mail). When we can reasonably and lawfully agree to your request, we will. However, we are permitted to charge you for any additional cost of sending your PHI to different addresses or by different means.
Your right to correct or update your PHI
If you believe there is a mistake in your PHI or that important information is missing, you may request that we correct or add to the record. Please write us and tell us what you are asking for and why we should make the correction or addition. We will respond in writing after receiving your request. If we approve your request, we will make the correction or addition to your PHI. If we deny your request, we will tell you why and explain your right to file a written statement of disagreement. You must clearly tell us in writing if you want us to include your statement in future disclosures we make of that part of your record. We may include a summary instead of your statement.
Your right to an accounting of disclosures of PHI
You may ask us for a list of our disclosures of your PHI. Please write us to request this accounting. The list we give you will include disclosures made in the last six years, unless you request a shorter time or if less than six years have passed since April 14, 2003. For example, if you requested a list of disclosures on April 14, 2005, the list would cover only two years. You are entitled to one disclosure accounting in any 12-month period at no charge. If you request any additional accountings less than 12 months later, we may charge a fee. An accounting does not include certain disclosures, for example, disclosures to carry out treatment, payment and health care operations; disclosures that occurred prior to April 14, 2003; disclosures for which AFMC had a signed authorization; disclosures of your PHI to you; disclosures for notifications for disaster relief purposes; or disclosures to persons involved in your care and/or acting on your behalf. Your right to request limits on uses and disclosures of your PHI You may request that we limit our uses and disclosures of your PHI for treatment, payment, and health care operations purposes. However, by law, we do not have to agree to your request.
Your right to receive a paper copy of this notice
You have a right to receive a paper copy of this notice upon request.
IV. HOW WE MAY USE AND DISCLOSE YOUR PHI
Our physicians and other volunteers are required to maintain the confidentiality of the PHI of our patients and we have policies and procedures and other safeguards to help protect your PHI from improper use and disclosure. Sometimes we are allowed by law to use and disclose certain PHI without your written permission. Several examples follow: How much PHI is used or disclosed without your written permission will vary depending, for example, on the intended purpose of the use or disclosure. Sometimes we may only need to use or disclose a limited amount of PHI, such as to send you an appointment reminder. At other times, we may need to use or disclose more PHI such as when we are providing medical treatment.
• Treatment: This is the most important use and disclosure of your PHI. For example, our physicians, dentists, nurses, and other health care personnel, including trainees, involved in your care use and disclose your PHI to diagnose your condition and evaluate your health care needs. Our personnel will use and disclose your PHI in order to provide and coordinate the care and services you need: for example, prescriptions, X-rays, and lab work. If you need care from health care providers who are not part of AFMC, such as community resources to assist with your health care needs, we may disclose your PHI to them.
• Treatment alternatives and health-related services: In some instances, the law permits us to contact you: 1) for your treatment; 2) for case management and care coordination; or 3) to recommend available treatment options, therapies, health care providers, or care settings.
• Payment: Your PHI may be needed to permit us to bill and collect payment for, treatment and health-related services that you receive.
• Health care operations: We may use and disclose your PHI for certain health care operations, for example, quality assessment and improvement, training and evaluation of health care professionals, licensing, accreditation, and determining other costs of providing health care.
• Business associates: We may contract with business associates to perform certain functions or activities on our behalf, such as payment and health care operations. These business associates must agree to safeguard your PHI.
• Appointment reminders: Your PHI allows us to contact you about appointments for treatment or other health care you may need.
• Specific types of PHI: There are stricter requirements for use and disclosure of some types of PHI, for example, mental health and drug and alcohol abuse patient information, HIV tests, and genetic testing information. However, there are still circumstances in which these types of information may be used or disclosed without your authorization.
• Communications with family and others when you are present: Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we won't discuss your PHI or we will ask the person to leave.
• Communications with family and others when you are not present: There may be times when it is necessary to disclose your PHI to a family member or other person involved in your care because there is an emergency, you are not present, or you lack the decision making capacity to agree or object. In those instances, we will use our professional judgment to determine if it's in your best interest to disclose your PHI. If so, we will limit the disclosure to the PHI that is directly relevant to the person's involvement with your health care. For example, we may allow someone to pick up a prescription for you.
• Disclosure in case of disaster relief: We may disclose your name, city of residence, age, gender, and general condition to a public or private disaster relief organization to assist disaster relief efforts, unless you object at the time.
• Disclosures to parents as personal representatives of minors: In most cases, we may disclose your minor child's PHI to you. In some situations, however, we are permitted or even required by law to deny your access to your minor child's PHI. An example of when we must deny such access, based on the type of health care, is when a minor who is twelve or older seeks care for a communicable disease or condition. Another situation when we must deny access to parents is when minors have adult rights to make their own health care decisions. These minors include, for example, minors who were or are married or who have a declaration of emancipation from a court.
• Research: Some of our research may involve medical procedures and some is limited to collection and analysis of health data. Research of all kinds may involve the use or disclosure of your PHI. Your PHI can generally be used or disclosed for research without your permission if an Institutional Review Board (IRB) approves such use or disclosure. An IRB is a committee that is responsible, under federal law, for reviewing and approving human subjects research to protect the safety of the participants and the confidentiality of PHI.
• Organ donation: We may use or disclose PHI to organ-procurement organizations to assist with organ, eye or other tissue donations.
• Public health activities: Public health activities cover many functions performed or authorized by government agencies to promote and protect the public's health and may require us to disclose your PHI.
- For example, we may disclose your PHI as part of our obligation to report to public health authorities certain diseases, injuries, conditions, and vital events such as births. Sometimes we may disclose your PHI to someone you may have exposed to a communicable disease or who may otherwise be at risk of getting or spreading the disease.
- We may use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety.
• Health oversight: As health care providers and health plans, we are subject to oversight conducted by federal and state agencies. These agencies may conduct audits of our operations and activities and in that process, they may review your PHI.
• Workers' compensation: In order to comply with workers' compensation laws, we may use and disclose your PHI. For example, we may communicate your medical information regarding a work-related injury or illness to claims administrators, insurance carriers, and others responsible for evaluating your claim for workers' compensation benefits.
• Military activity and national security: We may use or disclose the PHI of armed forces personnel to the applicable military authorities when they believe it is necessary to properly carry out military missions. We may also disclose your PHI to authorized federal officials as necessary for national security and intelligence activities or for protection of the president and other government officials and dignitaries.
• Marketing: AFMC may use and disclose your PHI to contact you about services, or supplies that we can offer you.
• Fundraising: We may use or disclose PHI to contact you to raise funds for our organization.
• Required by law: Sometimes federal or state law requires that we disclose your PHI to others. For example, the secretary of the Department of Health and Human Services may review our compliance efforts, which may include seeing your PHI.
• Lawsuits and other legal disputes: We may use and disclose PHI in responding to a court or administrative order, a subpoena, or a discovery request. We may also use and disclose PHI to the extent permitted by law without your authorization, for example, to defend a lawsuit or arbitration.
• Law enforcement: We may disclose PHI to authorized officials for law enforcement purposes, for example, to respond to a search warrant, report a crime on our premises, or help identify or locate someone.
• Serious threat to health or safety: We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to your health or safety or to someone else's.
• Abuse or neglect: By law, we may disclose PHI to the appropriate authority to report suspected child abuse or neglect or to identify suspected victims of abuse, neglect, or domestic violence.
• Coroners and funeral directors: We may disclose PHI to a coroner or medical examiner to permit identification of a body, determine cause of death, or for other official duties. We may also disclose PHI to funeral directors.
• Inmates: Under the federal law that requires us to give you this notice, inmates do not have the same rights to control their PHI as other individuals. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may disclose your PHI to the correctional institution or the law enforcement official for certain purposes, for example, to protect your health or safety or someone else's.
V. ALL OTHER USES AND DISCLOSURES OF YOUR PHI REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION
Except for those uses and disclosures described above, we will not use or disclose your PHI without your written authorization. When your authorization is required and you authorize us to use or disclose your PHI for some purpose, you may revoke that authorization by notifying us in writing at any time. Please note that the revocation will not apply to any authorized use or disclosure of your PHI that took place before we received your revocation. Also, if you gave your authorization to secure a policy of insurance, including health care coverage from us, you may not be permitted to revoke it until the insurer can no longer contest the policy issued to you or a claim under the policy.
VI. HOW TO CONTACT US ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you have any questions about this notice, or want to lodge a complaint about our privacy practices, please let us know by calling our Clinic Administrator at 510-407-AFMC (510-407-2362).
You also may notify the secretary of the Department of Health and Human Services (contact information provided below) We will not take retaliatory action against you if you file a complaint about our privacy practices.
VII. CHANGES TO THIS NOTICE
e may change this notice and our privacy practices at any time, as long as the change is consistent with state and federal law. Any revised notice will apply both to the PHI we already have about you at the time of the change, and any PHI created or received after the change takes effect. If we make an important change to our privacy practices, we will promptly change this notice and provide a new notice posted at Ashland Free Medical Clinic. Except for changes required by law, we will not implement an important change to our privacy practices before we revise this notice.
VIII. EFFECTIVE DATE OF THIS NOTICE
This notice is effective on April 14, 2003.
Contact information for the California Department of Health Services Privacy Officer:
California Department of Health Services,
P.O. Box 942732 Sacramento, CA 94234-7320
(916) 255-5259 or 1-877-735-2929 (TTY)