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.

This notice is provided to you on behalf of Daughters of Charity Health System.

If you have any questions about this notice, please contact the Privacy Official at the Local Health Ministry (“LHM”) where you received services. You can obtain the Privacy Official’s name by contacting the main number of the LHM.

WHO WILL COMPLY WITH THIS NOTICE:

This notice describes our LHM’s practices and that of:

• Any health care professional authorized to enter information into your LHM chart.
• All departments and units of the LHM.
• Any member of a volunteer group we allow to help you while you are at the LHM.
• All associates, staff and other LHM personnel.

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 LHM. We need this record to provide you with quality care and to comply with applicable legal requirements. This notice applies to all of the records of your care generated by the LHM, whether made by LHM personnel or your personal physician. Your personal physician may have different policies or notice regarding the physician’s use and disclosure of your medical information created in the physician’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 information.

We are required by law to:

• Make sure that medical information that identifies you is kept private.
• 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.

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 provide 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.

•  For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technicians, medical students, or other LHM personnel who are involved in taking care of you at the LHM. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the LHM 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 LHM who may be involved in your medical care after you leave the LHM, such as home care, family members, clergy or others we use to provide services that are part of your care.
• For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the LHM 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 performed on you at the LHM 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. We may use and disclose medical information about you to other health care professionals involved in your care to enable these professionals to obtain payment for the services they have provided to you.
• For Health Care Operations. We may use and disclose medical information about you for LHM operations. These uses and disclosures are necessary to run the LHM 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; some of the related LHM departments include Quality, Utilization/Case Management, Risk Management, Infection Control, Discharge Planning, and Social Services. We may also combine medical information about many LHM patients to decide what additional services the LHM should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to physicians, nurses, technicians, medical students and other LHM personnel for review and learning purposes. We may also combine our medical information with medical information from other LHMs 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 revealing who the specific patients are.
• Chaplain Services. As a Catholic health care ministry, our Mission is to provide care that is attentive to the whole person: body, mind, and spirit. In regards to care of your spiritual needs, we may disclose medical information about you to our Chaplain Services department, and you may be visited by one of our Chaplains. If you do not wish to be visited by our Chaplains, you may inform us, and your wishes will be respected.
• Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care at the LHM.
• 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.
• Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the LHM and its operations. We may disclose medical information to a foundation related to the LHM so that the foundation may contact you in raising money for the LHM. We would release only contact information, such as your name, address and phone number and the dates you received treatment or services at the LHM. If you do not want the LHM to contact you for fundraising efforts, you must notify the LHM Foundation in writing.
• LHM Directory. We may include certain limited information about you in the LHM directory while you are a patient at the LHM. This information may include your name, location in the LHM, your general condition (e.g., fair, stable, etc.) and your religious affiliation. This information is released so your family, friends and clergy can visit you in the LHM and generally know how you are doing. 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 do not ask for you by name.
• Individuals Identified by You as Involved in Your Care or Payment for Your Care and for Disaster Relief Circumstances. We may release directly relevant 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 LHM. In addition, 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.
• Research. 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 receive one medication to those who receive 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, so long as the medical information they review does not leave the LHM. We will almost always ask for your specific permission if the researcher needs access to your name, address or other information that reveals who you are, or will be involved in your care at the LHM.
• As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. This includes but is not limited to information about cancer diagnoses and treatment to the California Department of Health Services for the California Cancer Registry who may contact you regarding a cancer diagnosis or a request to participate in a research study that has been identified as beneficial to Public Health purposes, reporting of certain diseases to the Department of Health Services, certain birth defects to the California Birth Defects Program.
• 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.

SPECIAL SITUATIONS FOR RELEASING INFORMATION

• Organ and Tissue Donation. If you are an organ donor, 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 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.
• Workers’ Compensation. 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 Risks. 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 for 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.
• 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 (may include written notice) or to obtain an order protecting the information requested.
• Law Enforcement. 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 agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the LHM; 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 and Medical Examiners. 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.
• 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 (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.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

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. Contact the Health Information Management/Medical Records Department for further information or to request a form. 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.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 LHM 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 Request Restrictions on Certain Uses and Disclosures. You have the right to request that we restrict our uses and disclosures of your medical information in certain ways. For example, you may request that we not use or disclose such information in order to assist with our own treatment, payment, or health care operations. We are not required to agree to your request, except in narrow circumstances. We will inform you of our decision in writing.
• 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. Contact the Health Information Management/Medical Records Department for further information or to request a form. You have the right to request an amendment for as long as the information is kept by or for the LHM.To request an amendment, your request must be made in writing and submitted to the Health Information Management/Medical Records Department. 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 information that:

• Is not part of the medical information kept by or for the LHM; or
• Is not part of the information which you would be permitted to inspect and copy.

• Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures” which applies to disclosures of your health information we make outside the LHM, with certain exceptions.To obtain an accounting of disclosures, you must submit your request in writing. Your request must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, or electronically). Contact the Health Information Management/Medical Records Department for further information or to request a form. 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 Make Special Requests for Receiving 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 make special requests regarding confidential communications after your care, your request must be in writing and specify how or where you wish to be contacted. Contact the Health Information Management/Medical Records Department for further information or to request a form. 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. 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.

To obtain a paper copy of this notice, you may request a copy in person at any of the Admitting or Registration areas, in the Health Information Management/Medical Records Department, or the Privacy Officer during regular business hours.

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 LHM. The notice will contain the effective date. In addition, each time you register at or are admitted to the LHM for a new treatment or course of therapy as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the LHM or with the Secretary of the Department of Health and Human Services. To file a patient privacy complaint with the LHM, contact the LHM Privacy Officer. You can obtain the Privacy Officer’s name and contact information by calling the main number of the location where you received services. All complaints must be submitted in writing. You may also submit your complaints to the DCHS Corporate Responsibility Officer or DCHS Privacy Officer, 26000 Altamont Road, Los Altos Hills, CA 94022.

If you believe that your physician or another provider who is an independent contractor has violated your privacy, please contact that provider directly to file your complaint. The LHM is not authorized to investigate privacy violations of these providers.

You will not be penalized for filing a complaint.

PERMISSION FOR 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, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You should 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.

EFFECTIVE DATE OF THIS NOTICE

Effective April, 2003

Revised August, 2012