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.
If you are a newly admitted client to one of our programs (parent/guardian to a client of one of our programs), please make sure to sign the attached “Acknowledgement of Receipt of the Notice” and give it back to us for our records. If you have any questions about this notice, please see our contact information on the last page of this notice.
I. Who We Are
This Notice describes the privacy practices of Pacific Lodge Youth Services (PLYS), its therapists, social workers, case managers, youth care counselors, nurses, administrative staff, all other personnel, volunteers and contract staff. It applies to services furnished to you onsite and offsite.
All these entities follow the terms of this notice. In addition, these entities may share medical information with each other for treatment, payment or health care operations purposes described in this notice.
II. Our Privacy Obligations
We understand that your health information is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at PLYS. 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 PLYS.
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. Permissible Uses and Disclosures Without Your Written 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 of your PHI:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as described generally below:
• Treatment. We use and disclose your PHI to provide treatment and other services to you, for example to diagnose and treat your behavioral issues. 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”) or 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 therapists and other health care workers. We may share PHI with our program directors in order to resolve any complaints you may have and ensure that you have a comfortable visit with us. If complaints go directly to the program directors, the program directors are required to inform the privacy officer. The privacy officer keeps a “Log of complaints” in his/ her office.
• Other Providers. 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.
• Immunization Records: We may disclose proof of your immunization records to a school to ensure timely school enrollment, if the school is required by law to have such proof prior to admissions, and we obtain an agreement to the disclosure from the agent, guardian or other person acting in loco parentis or from the individual patient, if the individual is an adult or an emancipated minor.
B. Use or Disclosure of the client roster of Pacific Lodge Youth Services. We may include your name and your location at Pacific Lodge Youth Services, in the client roster without obtaining your authorization. Information in the roster will not be disclosed, which means that a client’s presence in our programs is never disclosed unless authorized by law.
C. Disclosure to Relatives, Close Friends and Other Caregivers involved in your care or payment for your care. 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. Disclosures to HHS. We may be required to disclose PHI to the Secretary of the Department of Health and Human Services to determine our compliance with federal privacy rules.
E. Disclosures to Business Associates. We may disclose your PHI to “business associates” who are third parties who assist us in performing various functions. Business Associates may include our IT department, our electronic health records vendor, contractors, consultants, lawyers, and outside billers. We require our business associates to safeguard your PHI.
F. Fundraising Communications. We DO NOT contact you or your parent/guardian to request a tax-deductible contribution to support important activities of Pacific Lodge Youth Services.
G. Public Health Activities. We may disclose your PHI for the following public health activities: (1) To prevent or control disease, injury or disability; (2) To report births and deaths; (3) To report regarding the abuse or neglect of children, elders and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; (6) 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; (7) To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.
H. 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.
I. Health Oversight Activities. We may disclose your PHI 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.
J. 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.
K. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law: (1) In response to a court order, subpoena, warrant, summons or similar process; (2) To identify or locate a suspect, fugitive, material witness, or missing person; (3) About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (4) About a death we believe may be the result of a criminal conduct; (5) About criminal conduct at Pacific Lodge Youth Services; and (6) 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.
L. Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.
M. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
N. Research. We may use your Protected Health Information for research projects. To do this, we will either ask your permission to use your Protected Health Information or we will use a special process that protects the privacy of your information. In addition, we may use information that cannot be identified as your Protected Health Information, but that includes certain limited information such as your date of birth and dates of service. We will use this information for research, quality assurance activities and other similar purposes, and we will obtain special protections for the information disclosed.
O. Health or Safety. We may use and disclose your PHI 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.
P. 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. We may use and disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may use and disclose your PHI to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or conduct special investigations.
Q. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose medical information about you to the correctional institution or law enforcement official. This disclosure 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.
R. 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.
S. Genetic Testing Information. If we keep genetic testing information about you, we will release that information only to the state departments that monitor our work or if required by law to release that information. Otherwise, we will give out this information only if you give us your permission in writing.
T. Communicable Disease Information. If you have a communicable disease, such as HIV/AIDS, we will provide that information to your health care provider, to providers engaged in organ procurement, or if required by law. For all other purposes, we will give out this information only with your permission.
U. Mental Health Information. Special protections apply to inpatient and outpatient mental health records, including psychotherapy notes. We will only disclose your mental health information in compliance with these special protections and will always seek your authorization, except when the use or disclosure is required for certain treatment, payment or health care operations activities or when we are permitted or required by law to release without authorization.
V. 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.
W. Sale of PHI. In general, a patient’s authorization is required for the sale of PHI. We DO NOT sell PHI of our clients!
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.
B. Marketing. Under most circumstances, we are required by law to obtain a written authorization (“Your Marketing Authorization”) prior to using your PHI for marketing purposes. (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. If we receive any direct or indirect payment for making such a communication, however, we would need your prior written permission to contact you. An exception for seeking such permission is when our communication describes only a drug or medication that is currently being prescribed for you and our payment for the communication is reasonable in amount.
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 Officer as provided for in Section VIII below. You may also file written complaints with the Director of the Office for Civil Rights of the U.S. Department of Health and Human Services at 90 7th Street, Suite 4-100, San Francisco, California 94103, Attention: Privacy Complaints; Phone: (415) 437-8310; Fax: (415) 437-8329; TDD: (415) 437-8311. Upon request, the Privacy Officer will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with the Director or us.
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, unless the disclosure is to a health plan for a payment or health care operation purpose and the medical information relates solely to a health care item or service for which we have been paid out-of-pocket in full. If you wish to request restrictions, please obtain a request form from our Privacy Officer and submit the completed form to the Privacy Officer. We will send you a written response.
C. Right to Receive Confidential Communications. You may request to receive your PHI by alternative means of communication or at alternative locations. For example, you can request that we only contact you at work or by mail. To request confidential communications, you must make your request in writing. We will not ask you for the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
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 Officer identified below. A form of Written Revocation is available upon request from the Privacy Officer.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us. You may inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you are denied access to PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital 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. If you desire access to your records, please obtain a record request form from the Privacy Officer and submit the completed form to the Privacy Officer. If your medical information is maintained in an electronic health record, you may obtain an electronic copy of your medical information and, if you choose, instruct us to transmit such copy directly to an entity or person you designate in a clear, conspicuous and specific manner. If you request paper copies, we will charge you $0.25 (Twenty-five cents) for each page. We will also charge you for our postage costs, if you request that we mail the copies to you. Our fee for providing you an electronic copy of your medical information will not exceed our labor costs in responding to your request for the electronic copy (or summary or explanation). You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s PHI 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 client records requested by the representative would have a detrimental effect on the provider’s professional relationship with the minor client 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 PHI 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 Officer and submit the completed form to the Privacy Officer. 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. 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: (1) Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) Is not part of the PHI kept by or for PLYS; (3) Is not part of the information which you would be permitted to inspect and copy; or (4) Is accurate and complete.
G. Right to Addendum. You have the right to add a 250-word document (“addendum”) to your PHI.
H. 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 six years prior to the date of your request, except that for requests made on or after January 1, 2011 that relate to treatment, payment or health care operation disclosures from our electronic health record system, the accounting period is three years. Your request should indicate in what form you want the list (for example, on paper or electronically). If you request an accounting more than once during a twelve (12) month period, we will charge you $0.25 (Twenty-five cents) per page of the accounting statement. If you desire to make a request for an accounting of disclosures, please obtain an accounting request form from the Privacy Officer and submit the completed form to the Privacy Officer.
I. Right to be Informed of Any Breach: We will notify you as required by law if
there has been a breach of your unsecured PHI.
J. 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, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website: www.plys.org. To obtain a paper copy of this notice, please ask your social worker/ therapist, if you are a client or the parent of a client of Pacific Lodge Youth Services. If you are a visitor, please ask the Officer of the Day or any receptionist.
IV. 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.
To the extent required by law, when using or disclosing your medical information or when requesting your medical information from another covered entity, we will make reasonable efforts not to use, disclose or request more than a limited data set (as defined below) of your medical information or, if needed by us, no more than the minimum amount of medical information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.
A limited data set means medical information that excludes the following items:
(ii) Postal address information, other than town or city, State, and zip code;
(iii) Telephone numbers;
(iv) Fax numbers;
(v) Electronic mail addresses;
(vi) Social security numbers;
(vii) Medical record numbers;
(viii) Health plan beneficiary numbers;
(ix) Account numbers;
(x) Certificate/license numbers;
(xi) Vehicle identifiers and serial numbers, including license plate numbers;
(xii) Device identifiers and serial numbers;
(xiii) Web Universal Resource Locators (URLs);
(xiv) Internet Protocol (IP) address numbers;
(xv) Biometric identifiers, including finger and voice prints; and
(xvi) Full face photographic images and any comparable images.
VII. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective starting October 1, 2016.
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 reception/ waiting areas at all operation and office sites of Pacific Lodge Youth Services and on our Internet site at www.plys.org. You also may obtain any new notice by contacting the Privacy Officer.
VIII. Privacy Officer
You may contact the Privacy Officer at:
Pacific Lodge Youth Services
4900 Serrania Avenue
Woodland Hills, CA 91364
Telephone Number: (818) 657-3104; E-mail: firstname.lastname@example.org
Includes HITECH changes that are appropriate after February 17, 2010 and
OMNIBUS LAW changes as appropriate after September 23, 2013!