Notice of Patient Privacy
Notice of Privacy Practice
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 have any questions about this notice, please contact the facility
Privacy Officer, Teri Conlon: phone (626) 307-2108; e-mail firstname.lastname@example.org.
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
- All departments and units of the hospital.
- Any member of a volunteer group we allow to help you while you are in the hospital.
- All employees, staff and other hospital personnel.
- All Outpatient Therapy staff members
All these entities, sites and locations follow the terms of this notice.
In addition, these entities, sites and
locations may share medical information with each other for treatment,
payment or health care operations
purposes described in this notice.
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 and services
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 of the records of your care generated by the hospital, whether
made by hospital personnel or your personal
doctor. Your personal doctor may have different policies or notices regarding
the doctor’s use and disclosure of
your medical information created in the doctor’s office or clinic.
This notice will tell you about the 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
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;
- Follow the terms of the notice that is currently in effect; and
- Notify you as required by law following a breach of your unsecured protected
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose
medical information. For each
category of uses or disclosures we will explain what we mean and try to
give some 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 one of the categories.
DISCLOSURE AT YOUR REQUEST
We may disclose information when requested by you. This disclosure at
your request may require a written
authorization by you.
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, health
care 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 dietitian 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, home health agencies, and physicians or
other practitioners. For example, we may
give your physician access to your health information to assist your physician
in treating you.
Business Associates: We may share your health information with our business associates
so they can perform the job we have asked them to do. Some services provided by our
business associates include a billing service, record storage company,
or legal or accounting
consultants. To protect your health information, we have written contracts
with our business
associates requiring them to safeguard your information.
Health Information Exchange: We, along with other health care providers in the Los
Angeles area, may participate in one or more Health Information Exchanges
(HIE). An HIE is
a community-wide information system used by participating health care
providers to share
health information about you for treatment purposes. Should you require
treatment from a
health care provider that participates in one of these exchanges who does
not have your
medical records or health information, that health care provider can use
the system to gather
your health information in order to treat you. For example, he or she
may be able to get laboratory or
other tests that have already been performed or find out about treatment(s) that
you have already received. We will include your health information in
this system. If you
would prefer your information not be shared with the HIE (opt-out) or
have previously opted
out of HIE participation and would like to share your information with
the HIE (opt-in), please
notify your registration staff or the business office at the facility
where you obtain health care.
The staff can help you change your preference using the HIE Change of
Sharing Status form.
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 information about surgery you received at
the hospital to your health plan so it
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. We may also
provide basic information about you and your health plan, insurance company
or other source of payment to
practitioners outside the hospital who are involved in your care, to assist
them in obtaining payment for services
they provide to you.
FOR 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 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 combine
the medical information we have
with medical information from other hospitals to 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 to study health care and health
care delivery without learning who the
specific patients are.
We may use information about you, or disclose such information to a foundation
related to the hospital, to
contact you in an effort to raise money for the hospital and its operations.
You have the right to opt out of
receiving fundraising communications. If you receive a fundraising communication,
it will tell you how to opt
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., good,
fair, 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 a 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.
MARKETING AND SALE
Most uses and disclosures of medical information for marketing purposes,
and disclosures that constitute a sale
of medical information, require your authorization.
TO 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
In addition, we may disclose medical information about you to an organization
assisting in a disaster relief
effort so that your family can be notified about your condition, status
and location. If you arrive at the
emergency department either unconscious or otherwise unable to communicate,
we are required to attempt to
contact someone we believe can make health care decisions for you (e.g.,
a family member or agent under a
health care power of attorney).
Under certain circumstances, we may use and disclose 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 the 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, as long as
the medical information they review does not leave 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
We may release medical information to organizations that handle organ procurement
or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to facilitate
organ or tissue donation and
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.
We may release medical information about you for workers’ compensation
or similar programs. 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
- To prevent or control disease, injury or disability;
- To report births and deaths;
- To report regarding 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;
- To notify the appropriate government authority if we believe a patient
has been the victim of abuse, neglect or domestic violence. We will only
make this disclosure if you agree or when required or
authorized by law;
- To notify emergency response employees regarding possible exposure to HIV/AIDS,
to the extent necessary to comply with state and federal laws.
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, but only if efforts have been
made to tell you about the request (which may include written notice to
you) or to obtain an order protecting the
We may release medical information if asked to do so by a law enforcement official:
- 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
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital; and
- 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
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES
We may release medical information about you to authorized federal officials
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.
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.
MULTIDISCIPLINARY PERSONNEL TEAMS
We may disclose health information to a multidisciplinary personnel team
relevant to the prevention,
identification, management or treatment of an abused child and the child’s
parents, or elder abuse and neglect.
SPECIAL CATEGORIES OF INFORMATION
In some circumstances, your health information may be subject to restrictions
that may limit or preclude some
uses or disclosures described in this notice. For example, there are special
restrictions on the use or disclosure of
certain categories of information — e.g., tests for HIV or treatment
for mental health conditions or alcohol and
drug abuse. Government health benefit programs, such as Medi-Cal, may
also limit the disclosure of beneficiary
information for purposes unrelated to the program.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain
RIGHT TO INSPECT AND COPY
You have the right to inspect and obtain a copy of 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
To inspect and obtain a copy of medical information that may be used to
make decisions about you, you must
submit your request in writing to the Release of Information Clerk. To
obtain a request form call (626) 300-
0263. If you request a copy of the information, we may charge a fee for
the costs of copying, mailing or other
supplies associated with your request. You may request an electronic copy
of your records if available.
We may deny your request to inspect and obtain a 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 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
To request an amendment, your request must be made in writing and submitted
to [insert contact information].
In addition, you must provide a reason that supports your request.
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
- 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 or for the hospital;
- Is not part of the information which you would be permitted to inspect
and 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 for our own uses for treatment,
payment and health care operations
(as those functions are described above), and with other exceptions pursuant
to the law.
To request this list or accounting of disclosures, you must submit your
request in writing to the facility Privacy
Officer, Teri Conlon: phone (626) 307-2108 or e-mail email@example.com.
must state a time period which may not be longer than the six previous
years and may not include dates before
April 14, 2003. 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. You also have the right
to request a limit on the medical
information we disclose about you 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
We are not required to agree to your request, except to the extent that
you request us to restrict disclosure to a
health plan or insurer for payment or health care operations purposes
if you, or someone else on your behalf
(other than the health plan or insurer), has paid for this item or service
out of pocket in full. Even if you request
this special restriction, we can disclose the information to a health
plan or insurer for purposes of treating you.
If we agree to another special restriction, 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 facility
Privacy Officer, Teri Conlon:
phone (626) 307-2108 or e-mail firstname.lastname@example.org. In your request,
you must tell us 1) what
information you want to limit; 2) whether you want to limit our use, disclosure
or both; and 3) to whom you
want the 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 facility Privacy Officer,
Teri Conlon: phone (626) 307-2108 or e-mail email@example.com.
We will not ask you the
reason for your request. We will accommodate all reasonable requests.
Your request must specify how or where
you wish to be contacted.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this notice. You may ask us to give
you a copy of this notice at any time.
Even if you have agreed to receive this notice electronically, you are
still entitled to a paper copy of this notice.
You may obtain a copy of this notice at our website: http://www.montereyparkhosp.com.
To obtain a paper
copy of this notice contact the facility Admitting Department at (626) 570-5720.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make
the revised or changed 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. The notice will contain
the effective date on the first page, in
the 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 U.S. Department of Health and Human Services. To file
a complaint with the hospital, contact
the facility Privacy Officer, Teri Conlon: phone (626) 307-2108 or e-mail
All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
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.