Effective Date: September 23, 2013
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. You may contact Huntington Hospital’s Compliance Officer at (626) 397-5335 with questions.
Who will follow this notice
This notice describes our hospital’s practices and that of:
- Any health care professional authorized to enter information into your hospital chart, including doctors and other health care providers who participate in your care and treatment at the hospital.
- Any hospital sponsored volunteer group we allow to assist you while you are in the hospital.
- All hospital employees, staff and other hospital personnel.
- All departments, clinics and units of the hospital.
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 you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by the hospital, whether made by the hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of you medical information created in the doctor’s office or clinic.
This notice will tell you about 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;
- notify you of any breach of your unsecured medical information; and
- follow the terms of the version of this Notice of Privacy Practices 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, including several 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 on of these categories.
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 hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as skilled nursing facilities or home health agencies.
Payment: We may use and disclose medical information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also 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.
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 hospital and make sure that all of our patients receive quality care. For example, we may use and disclose 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 hospital patients to decide what additional services the hospital 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 hospital personnel for review and learning purposes. We may also 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 yo study health care and health care delivery without learning who the specific patients are.
Organized health Care Arrangement: We may use and disclose medical information with doctors and other health care providers who care for and treat patients at the hospital as necessary to carry out treatment, payment and health care operations related to arrangements with them for health care services provided at the hospital, inclusive or radiologists, pathologists, anesthesiologists and others may provide you with services.
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 hospital.
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 Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you, including information about other providers or settings, other treatments or therapies, or payment for such products or services.
Fundraising Activities: We may use medical information about you to contact you in an effort to raise money for the hospital and its operations. We would only use contact information, such as your name, address and phone number and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify the Development Department at Huntington Hospital, in writing or by calling (626) 397-3241.
Hospital Directory: We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as priest or rabbi, even if they don’t ask for you by name. This information is released so your family, friends and clergy can visit you in the hospital and generally know how you are doing.
Business Associates: We may disclose medical information to those that we contract with as business associates so that they may perform services for us or on our behalf. For example, we may send tapes to an outside vendor for transcription. We require that business associates implement appropriate safeguards to protect your medical information.
Personal Representatives: We may disclose medical information to your “personal representative,” a person who has authority to act on your behalf and make decisions related to your health care.
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. Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the hospital.
Research: Under certain circumstances, we may use and disclosure medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. 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 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 hospital. We will almost always ask for your specific permission if the researcher will be involved in your care at the hospital.
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.
Organ and Tissue Donation: If you are a potential organ donor, we may release medical information to organizations that handle organ procurement or organ, eye and 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.
Worker’s Compensation: We may release medical information about you for worker’s compensation or similar programs, as permitted by applicable law. These programs provide benefits for work-related injuries or illness.
Public Health Activities: 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; and
- To provide student immunization records to a school that is required by law to obtain proof of immunization, based on your or your personal representative’s permission.
Victim of Abuse, Neglect, or Domestic Violence: We may notify the appropriate government authority and disclose medical information regarding a patient we reasonably believe to be a victim of abuse, neglect or domestic violence. We generally will inform you that such disclosure has been or will be made.
Disaster Relief: We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
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, subject to certain limits to protect your privacy, such as a protective order or notice to you and an opportunity for you to object.
Law Enforcement: We may release medical information if asked to do so by a law enforcement official for law enforcement activities, such as:
- 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 reslt of criminal conduct;
- About criminal conduct at the hospital; or
- 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.
Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.
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 for:
- the institution to provide you with health care;
- to protect your health and safety or the health and safety of others;
- for the safety of the correctional institution.
Privacy Rule Investigation: We may disclose medical information to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining the hospital’s compliance with applicable law.
Special Categories of Information: Certain categories of information – e.g., treatment and services for mental health conditions or alcohol and drug abuse; tests for the human immunodeficiency virus (HIV) – may require special handling or treatment under the law. We will handle these special categories of information in accordance with these requirements.
Other uses of medical information
Other uses and disclosures of medical information that are not covered by this notice or allowed by applicable law will not be made without your written permission. We generally will only make the following uses and disclosures of medical information if we have received your authorization:
- Uses and disclosures of psychotherapy notes;
- Disclosures of your medical information in exchange for remuneration; and
- Uses and disclosures of your medical information for marketing purposes.
If you provide us permission to use or disclose medical information about you, you may revoke that permission in writing at any time. We will cease any further use or disclosure of your medical information for the purposes covered by your written authorization from the time you revoke (this does not include uses and disclosures we have already made while relying on your past 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.
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 the Medical Records Department of the hospital. If you request a copy of the information, we will charge a nominal fee for the costs of copying, mailing or other supplies associated with your request. Fees for these services can be obtained at the time of the 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 hospital will review your request and the denial. The person conducting the review will not be the same 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 hospital. Your request for an amendment must be made in writing, submitted to the Medical Records Department, and must include a reason that supports your request, or we may deny 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 the hospital;
- Is not part of the information which you would be permitted to inspect or 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 of accounting of disclosures, you must submit your request in writing to the Medical Records Department. Your request must state a time period which may be no longer than six years prior to the date of the request. Your request should indicate in what form you want the list (for example, on paper or 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, or 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, except if you pay fa your health care services in full out of pocket, we must agree to restrict our disclosures to your health plan for payment or health care operations unless the disclosure is required by law. 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 the Medical Records Department and tell us:
- what information you want to limit;
- whether you want to limit our use, disclosure or both; and
- to whom you want 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 the Patient Access Department and specify how or where you wish to be contacted. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may ask us to give you a copy of this notice at any time by calling Huntington Hospital’s Compliance Officer at (626) 397-5335, or you may obtain a copy at www.huntingtonhospital.com.
Changes to this notice
We reserve the right to change this notice and to make the revised 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 hospital and at www.huntingtonhospital.com. The notice will contain the effective date (first page, top right hand corner). In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. Written complaints should be sent to the hospital at the following address: Huntington Hospital, 100 W. California Boulevard, Pasadena, California, 91105, Attn: Compliance Officer. All complaints must be submitted in writing, but you may contact the Compliance Officer at (626) 397-5335 with questions or other concerns. You will not be penalized for filing a complaint.