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.
Effective Date. 04/14/03
Anyone has the right to ask for a paper copy of this notice at
any time. You may download a copy of this form in Adobe Acrobat PDF
format here (19K).
Q. Why are you providing this notice to
me?
A. We are required by a new federal law, the Health
Insurance Portability and Accountability Act (HIPAA), to make sure that
your Protected Health Information (PHI) is kept private. We must give
you this notice of our legal duties and privacy practices with respect
to your PHI. We are also required to follow the terms of the notice that
is currently in effect. PHI includes information that we have created or
received about your past, present, or future health or medical condition
that could be used to identify you. It also includes information about
medical treatment you have received and about payment for health care
you have received. We are required to tell you how, when, and why we use
and/or share your personal health information (PHI).
Q. How and when can you use or disclose my
PHI?
A. HIPPA and other laws allow or require us to use or
disclose your PHI for many different reasons. We can use or disclose
your PHI for some reasons without your written agreement. For other
reasons, we need you to agree in writing that we can use or disclose
your PHI. We describe in this Notice the reasons we may use your
personal health information without getting your permission. Not every
use or disclosure is listed, but the ways we can use and disclose
information are all within one of the descriptions below. You may
request a list of disclosures of your PHI by downloading, completing and
returning this form (11K -
Adobe Acrobat PDF format) to our department at 806 South Main Street,
Yreka California, 96097. You may also request this form in person at the
department.
So you can receive treatment. We may use and disclose
your PHI to those who provide you with health care services or who are
involved in your care. These people may be doctors, nurses, and other
health care professionals. For example, if you are being treated for a
knee injury, we may give your PHI to the people involved in your
physical therapy. We many also use your PHI so that health care can be
offered or provided to you by a health agency.
To get payment for your treatment. We may use and
disclose your PHI in order to bill and get paid for treatment and
services you receive. For example, we may give parts of your PHI to our
billing or claims department or others who do these things for us. They
can use it to make sure your health care providers are paid correctly
for the health care services you received under a health plan.
To operate our business. We may use and disclose your
PHI in order to administer our health plans. For example, we may use
your PHI in order to review and improve the quality of health services
you receive. We may also provide your PHI to our accountants, attorneys,
consultants, and others in order to make sure we are obeying the laws
that affect us. Another time when we may provide PHI to other
organizations is when we ask them to tell us about the quality of our
health plans and how we operate our business. Before we share PHI with
other organizations, they must agree to keep our PHI private.
To meet legal requirements. We share PHI with
government or law enforcement agencies when federal, state, or local
laws require us to do so. We also share PHI when we are required to in a
court or other legal proceedings. For example, If a law says we must
report private information about people who have been abused, neglected,
or are victims of domestic violence, we share PHI.
To report public health activities. We share PHI with
government officials in charge of collecting certain public health
information. For example, we may share PHI about births, deaths, and
some diseases. We may provide coroners, medical examiners, and funeral
directors information that relates to a person’s death.
For health oversight activities. We may share PHI if a
government agency is investigating or inspecting a health care provider
or organization.
For purposes of organ donation. Even though the law
permits it, we do not share PHI with organizations that help find
organs, eyes, and tissue to be donated or transplanted.
For research purposes. We do not use or disclose your
PHI in order to conduct medical research.
To avoid harm. In order to avoid a serious threat to
the health or safety of a person or the public, we may provide PHI to
law enforcement or people who may be able to stop or lessen the harm.
For specific government functions. We may share PHI for
national security reasons. For example, we may share PHI to protect the
president of the United States. In some situations, we may share the PHI
of veterans and people in the military when required by law.
For workers’ compensation purposes. We may share PHI to
obey workers compensation laws.
Appointment reminders and health-related benefits or services.
We may use PHI to send you appointment reminders. We may also use PHI to
give you information about other health care treatment, services, or
benefits.
Fundraising activities. Even though permitted by law,
we do not use or disclose your PHI to contact you in order to raise
funds for our business or related charities.
Other uses and disclosures require your prior written agreement.
In other situations, we will ask for your written permission before we
use or disclose your PHI. You may decide later that you no longer want
to agree to a certain use of your PHI for which we received your
permission. If so, you may tell us that in writing. We will then stop
using your PHI for that certain situation. However, we may have already
used your PHI. If we had your permission to use your PHI when we used
it, you cannot take back your agreement for those past situations.
Q. Will you give my PHI to my family,
friends, or others?
A. We may share medical information
about you with a friend or family member who is involved in or who helps
pay for your medical care when you are present.
In order to enroll you in a health plan, we may share limited PHI with
your employer or other organizations that help pay for your membership
in the plan. However, if your employer or another organization that pays
for your membership asks for specific PHI about you, we will get your
permission before we disclose your PHI to them.
There may be a situation in which you are not present or you are unable
to make a health care decision for yourself. We may use or share your
PHI if professional judgment says that doing so is in your best
interest. For example, if you are unconscious and a friend is with you,
we may share your PHI with your friend so you can receive care.
Q. What are my rights with respect to my
PHI?
A. You have the right to ask that we limit how we use
and give out your PHI. You also have the right to request a limit on the
PHI we give to someone who is involved in your care or helping pay for
your care, like family member or friend. For example, you could ask that
we not use or disclose information about a treatment you had. We will
consider your request. However, we are not required to agree to the
request. If we accept your request, we will put any limits in writing.
We will honor these limits except in emergency situations. You may not
limit the ways we use and disclose PHI when we are required to make the
use or disclosure.
You have the right to ask that we send your PHI to you at an address of
your choice or to communicate with you in a certain way if you tell us
that this is necessary to protect you from danger. You must tell us in
writing what you want and what the reason is you could be put in danger
if we do not meet your request. For example, you may ask us to send PHI
to your work address instead of your home address. You may ask that we
send your PHI by e-mail rather than regular mail.
You have the right to look at or get copies of your PHI that we have.
You must make that request in writing. You can get a form to request
copies or look at your PHI by calling Public Health Department at
530/841-4040. If we do not have your PHI, we will tell you how you may
be able to get it. We will respond to you within 30 days after we
receive your written request. In certain situations, we may deny your
request. If we do, we will tell you, in writing, the reasons we are
denying your request.
If you ask for your PHI, we will charge you a reasonable fee based on
the cost of copying and postage. We can send you all your PHI, or if you
request, we may send you a summary or general explanation of your PHI if
you agree to the cost of preparing and sending it.
You have the right to get a list of instances in which we have given out
your PHI. This list will not include: a) disclosures we made so you
could get treatment: b) disclosures we made so we could receive payment
for your treatment: c) disclosures we made in order to operate our
business: d) disclosures made directly to you or to people you
designated: e) disclosures made for national security purposes: f)
disclosures we made when we had your written permission.
We will respond within 60 days of receiving your written request. The
list we give you can only include disclosures made after April 14, 2003,
the date this notice became effective. We cannot provide you a list of
disclosures made before this date. You may request a list of disclosures
made the six years (or fewer) preceding the date of your request. The
list will include a) the date of the disclosure: b) the person to whom
PHI was disclosed (including their address, if known): c) a description
of the information disclosed: and d) the reason for the disclosure. We
will give you one list of disclosures per year for free. If you ask for
another list in the same year, we will send you one if you agree to pay
the reasonable fee we will charge for the additional list.
You have the right to ask us to correct your PHI or add missing
information if you think there is a mistake in your PHI. You must send
us your request in writing and give the reason for your request. You can
get a form for making your request by calling Public Health Department
at 530/841-4040. We will respond within 60 days of receiving your
written request. If we approve your request, we will make the change to
your PHI. We will tell you that we have made the change. We will also
tell others who need to know about the change to your PHI.
We may deny your request if your PHI is a) correct and complete: b) not
created by us: c) not allowed to be disclosed: or d) not part of your
records. If we deny your request, we will tell you the reasons in
writing. Our written denial will also explain your right to file a
written statement of disagreement. You have the right to ask that your
written request, our written denial, and your statement of disagreement
be attached to your PHI anytime we give it out in the future.
Q. How may I complain about your privacy
practice?
A. If you think that we may have violated your privacy
rights, you may send your written complaint to the Director of Nursing,
806 South Main Street, Yreka, California, 96097. You also may make a
complaint to the Secretary of the Department of Health and Human
Services. You will not be penalized for filing a complaint about our
privacy practices.
Q. How will I know if my rights described
in this notice change?
A. We reserve the right to change the terms of this
notice and our privacy policies at any time. Then the new notice will
apply to all your PHI. If we change this notice, we will put the new
notice on our website at
http://www.co.siskiyou.ca.us/phs/phs.aspx and provide a copy of the
new notice to our clients.
Q. Who should I contact to get more
information or to get a copy of this notice?
A. For more information about your privacy rights
described in this notice, or if you want another copy of the notice,
please visit our website at
http://www.co.siskiyou.ca.us/phs/phs.aspx where you can download
this notice. You may also write us at County of Siskiyou Public Health
Department, 806 South Main Street, Yreka, California, 96097. For further
information you may consult Federal Privacy Regulations, set out at 45
C.F.R. Pats 160 & 164.