This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review
I. Who We Are
This Notice describes the privacy practices of
CASA COLINA ENTITY, its physicians, nurses, rehabilitation staff and other personnel. It
applies to services furnished to you at 255 East Bonita Avenue, Pomona,
II. Our Privacy Obligations
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 disclosure your
PHI. However, we do not need any type of authorization from you for the
following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations.
We may use and disclosure PHI but not your "Highly Confidential Information"
(defined in Section IV.C below), in order to treat you, obtain payment
for services provided to you and conduct our "health care operations"
as detailed below:
- Treatment. We use and disclose your PHI to provide treatment and other
services to you, for example, to diagnose and treat your injury or illness.
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 disclosure 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") 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 physicians, nurses, and other health
care workers. We may disclose PHI to our Administrative staff in order
to resolve any complaints you may have and ensure that you have a comfortable
visit with us.
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
B. Use or Disclosure for Directory of Individuals in
CASA COLINA ENTITY . We may include your name, location in
CASA COLINA ENTITY , general health condition and religious affiliation in a patient directory
without obtaining your authorization unless you object to inclusion in
the direction. Information in the directory may be disclosed to anyone
who asks for you by name or members of the clergy; provided, however,
that religious affiliation will only be disclosed to members of the clergy.
C. Disclosure to Relatives, Close Friends and Other Caregivers. 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 interests. 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. Fundraising Communications. We may contact you to request a tax-deductible
contribution to support important activities of
CASA COLINA ENTITY . In connection with any fundraising, we may disclose to our fundraising
staff demographic information about you (e.g., your name, address and
phone number) and dates on which we provided health care to you, without
your written authorization. If you do not want to receive any fundraising
requests in the future, you may contact our Foundation Office at 909/596-7733
E. Public Health Activities. We may disclose your PHI for the following
public health activities: (1) to report health information to public health
authorities for the purpose of preventing or controlling disease, injury
or disability; (2) to report child abuse and neglect to public health
authorities or other government authorities authorized by law to receive
such reports; (3) to report information about products and services under
the jurisdiction of the U.S. Food and Drug Administration; (4) to alert
a person who may have been exposed to a communicable disease or may otherwise
be at risk of contracting or spreading a disease or condition; and (5)
to report information to your employer as required under laws addressing
work-related illnesses and injuries or workplace medical surveillance.
F. 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.
G. Health Oversight Activities. We may disclose your PHI to a health oversight
agency that oversees the health care system and is charged with responsibility
for ensuring compliance with the rules of government health programs such
as Medicare or Medicaid.
H. 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.
I. Law Enforcement Officials. We may disclose your PHI to the police or
other law enforcement officials as required or permitted by law or in
compliance with a court order or a grand jury or administrative subpoena.
J. Decedents. We may disclose your PHI to a coroner or medical examiner
as authorized by law.
K. Organ and Tissue Procurement. We may disclose your PHI to organizations
that facilitate organ, eye or tissue procurement, banking or transplantation.
L. Research. We may use or disclose your PHI without your consent or authorization
if our Institutional Review Board approves a waiver of authorization for
M. Health or Safety. We may use or disclose your PHI to prevent or lessen
a serious and imminent threat to a person's or the public's health
N. 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.
O. 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.
P. 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.
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
Your Authorization "). For instance, you will need to execute an authorization form
before we can send your PHI to your life insurance company or to the attorney
representing the other party in litigation in which you are involved.
B. Marketing. We must also obtain your written authorization ("
Your Marketing Authorization ") prior to using your PHI to send you any marketing materials. (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.
C. Uses and Disclosures of Your Highly Confidential Information. In addition,
federal and California law requires special privacy protections for certain
highly confidential information about you ("
Highly Confidential Information "), including the subset of your PHI that: (1) is maintained in psychotherapy
notes; (2) is about mental health and developmental disabilities services;
(3) is about alcohol and drug abuse prevention and treatment; (4) is about
HIV/AIDS testing, diagnosis or treatment; (5) is about communicable disease(s);
(6) is about genetic testing; (7) is about child abuse and neglect; (8)
is about domestic and elder abuse or (9) is about sexual assault. In order
for use to disclose your Highly Confidential Information for a purpose
other than those permitted by law, we must obtain your written authorization.
In accordance with federal and California law, there are specific situations
in which Highly Confidential Information may be released without the patient's
1. Substance abuse information may be released in the following situations:
a. Program Personnel: Communication of information between or among personnel
who need such information to diagnose, treat, or refer for treatment of
alcohol or drug abuse, if the communications are within a program or between
a program and an entity that has direct administrative control over the program.
b. Qualified Service Organizations: Communications between a program and
a qualified service organization of information needed by the organization
to provide services to the program (See 42 C.F.R. section 2.11 for definitions).
c. Crimes on Program Premises or Against Program Personnel: Communications
from program personnel to law enforcement officers that are directly related
to a patient's commission of a crime on program premises or against
program personnel or to a threat to commit such crime and are limited
to the circumstances of the incidents (See 42 C.F.R. section 2.12 (c)(5)).
d. Child Abuse Reports: Reports of suspected child abuse and neglect under
California law to the appropriate authorities (42 C.F.R. section 2.12 (c)(6)).
e. Veterans' Administration and Armed Forces: Certain exceptions apply
to records and information maintained by the Veterans' Administration
and Armed Forces (42 C.F.R. section 2.12 (c)(1)).
f. Medical Emergencies: Information may be disclosed to medical personnel
who need the information to treat a condition which poses an immediate
threat to the health of any individual and which requires immediate medical
intervention (See 42 C.F.R. section 2.51 (b) for other situations involving
g. Research Activities: Information may be disclosed for the purpose of
conducting scientific research if the program director determines that
the recipient of the patient-identifiable information will be maintained
in accordance with specified security requirements under the regulations
(See 42 C.F.R. section 2.16 for security requirements and section 2.52
for other restrictions related to research activities).
h. Audit and Evaluation Activities: Information may be disclosed for audit
by an appropriate federal, state or local governmental agency that provides
financial assistance to the program or is authorized by law to regulate
its activities; a third party payer covering patients in the program;
a private person or entity that provides financial assistance to the program;
a peer review organization performing utilization or quality control review;
or an entity authorized to conduct a Medicare or Medicaid audit or evaluation
(See 42 C.F.R. section 2.53 for certain restrictions involving audit and
2. Reports of suspected child abuse or neglect and information contained
therein may be disclosed only to:
a. Law enforcement
b. Child welfare agency
c. Licensing agency (the state agency responsible for licensing the agency
3. Reports of elder and dependent adult abuse may be disclosed only in
these following situations:
a. Information relevant to the incident of elder or dependent adult abuse
may be given to an investigator from an adult protective services agency,
a local law enforcement agency, the Bureau of Medi-Cal fraud, or investigators
from the Department of Consumer Affairs, Division of Investigation who
are investigating the know or suspected cause of elder or dependent adult abuse.
b. Persons who are trained and qualified to serve on multidisciplinary
personnel teams may disclose to one another information and records that
are relevant to the prevention, identification, or treatment of abuse
of elderly or dependent adults.
c. The health care provider may disclose medical information covered by
the Confidentiality of Medical Information Act, Civil Code section 56, et seq.
d. The health care provider may disclose mental health information covered
by Welfare and Institutions Code section 5328.
e. Information from elder abuse reports and investigations, except for
the identity of persons who have made reports.
f. Information pertaining to reports by health practitioners of persons
suffering from physical injuries inflicted by means of a firearm or of
persons suffering physical injury where the injury is a result of assaultive
or abusive conduct.
g. Information protected by the physician-patient or psychotherapist-patient
4. HIV test results may be disclosed to the following persons without the
written authorization of the subject of the test:
a. To the subject of the test or the subject's legal representative,
conservator, or to any person authorized to consent to the act.
b. To a test subject's provider of health care, as defined in Civil
Code section 56.05 (h).
c. To an agent or employee of the test subject's provider of health
care who provides direct patient care and treatment.
d. To a provider of health care who procures, processes, distributes or
uses a human body part donated pursuant to the Uniform Anatomical Gift Act.
e. To the "designated officer" of an "emergency response
employee" (as those terms are used in the Ryan White Comprehensive
AIDS Resources Emergency Act of 1990).
f. To a procurement organization, a coroner, or a medical examiner in conjunction
with organ donation.
g. To a health care worker who has been exposed to the potentially infectious
materials of a patient provided that strict procedures for testing and
consent are followed.
h. To specified categories of persons, where the test has been performed
on a criminal defendant pursuant to Health and Safety Code sections 121050-121065.
i. To an officer in charge of adult correctional or juvenile detention
facilities that an inmate or minor at such facility has been exposed or
infected by the AIDS virus or has an AIDS-related condition or other communicable
disease (See Health and Safety Code section121070 for information subject
5. Communicable diseases (See Title 17, California Code of Regulations
section 2504 for a list of diseases that must be reported).
a. Health care facilities and clinics must establish administrative procedures
to assure that reports are made to the local health officer.
b. Where no health care provider is in attendance, any individual having
knowledge of a person who is suspected to have one of the diseases listed
in Title 17, California Code of Regulations section 2504 may make a report
to the local health officer for the jurisdiction in which the patient resides.
c. Disease notifications must include, if known, the following information:
the name of the disease or condition; the date of onset; the date of diagnosis;
the name, address, telephone number, occupation, race/ethnic group, social
security number, sex, age, and the date of birth of the patient; the date
of death when applicable; and the name, address, and telephone number
of the person making the report.
6. Release of mental health and developmental disability information requires
the written authorization of the patient only to the person listed below:
a. The patient's attorney, upon presentation for release of information
authorization signed by the patient (See Evidence Code section 1158 for
authorization requirements). If the patient is unable to sign, the facility
may release records to the attorney, if the staff has determined that
the attorney does not represent the interests of the patient.
b. A person designated by the patient, provided the professional in charge
of the patient gives approval; patient consent is not required (See Welfare
and Institutions Code sections 5328.6 and 5328.7 for additional requirements).
c. A person designated in writing by a patient's parent, guardian,
conservator, or guardian ad litem; if the patient is a minor, ward or
conservatee, patient's consent is not required (See Welfare and Institutions
Code sections 5328.6 and 5328.7 for additional requirements).
d. A professional person who does not have the medical or psychological
responsibility for the patient's care and who is not employed by the
facility that maintains the record (See Welfare and Institutions Code
sections 5328.6 and 5328.7 for additional requirements).
e. A life or disability insurer provided the patient designates the insurer
f. A qualified physician or psychiatrist who represents an employer to
which the patient has applied for employment unless the physician or administrative
officer responsible for the care of the patient deems the release contrary
to the best interests of the patient (See Welfare and Institutions Code
section 5328.9 for additional requirements).
g. A probation officer charged with the evaluation of a person after his
or her conviction of a crime if the person has been previously confined
in, or otherwise treated by, a facility (See Welfare and Institutions
Code section 5328 (k) for additional requirements).
h. An applicant for, or recipient of, services from the state Department
of Developmental Services (or the person's authorized representative)
for the purpose of appealing an adverse eligibility or benefits decision
(See Welfare and Institutions Code section 4726 - 2730 for additional
i. A county patients' rights advocate upon presentation of written
authorization, signed by the patient who is the advocate's "client"
or by the "client's" guardian ad litem (See Welfare and
Institutions Code section (m) and 5546 for additional requirements and
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 Office. You may also file written complaints
with the Director, Officer for Civil Rights of the U.S. Department of
Health and Human Services. Upon request, the Privacy Office will provide
you with the correct address for the Director. We will not retaliate against
you if you file a complaint with us or the Director.
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.If
you wish to request additional restrictions, please obtain a request form
from our Privacy Officer and submit the completed form to the Privacy
Office. We will send you a written response.
C. Right to Receive Confidential Communications. You may request, and we
will accommodate, any reasonable [
written ] request for you to receive your PHI by alternative means of communication
or at alternative locations.
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 Office .]
E. Right to Inspect and Copy Your Health Information. You may request access
to your medical record file and billing records maintained by us in order
to inspect and request copies of the records. Under limited circumstances,
we may deny you access to a portion of your records. If you desire access
to your records, please obtain a record request from the Registration
Area, Admissions Department, Health Information Management Department,
or the Privacy Office and submit the completed form to the same office.
If you request copies, we will charge you $0.20 (twenty cents) for each
page.We will also charge a $16.00 per hour processing fee billed in quarter
hours with a minimum charge of $4.00. We will also charge you for our
postage costs, if you request that we mail the copies to you.
F. Right to Amend Your Records. You have the right to request that we amend
Protected Health Information 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 Office and submit the completed
form to the Privacy Office. 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.
G. 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 prior to the date of your request provided such period
does not exceed six years and does not apply to disclosures that occurred
prior to April 14, 2003. If you request an accounting more than once during
a twelve (12) month period, we will charge you $1.00 per page of the accounting
H, 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
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
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 waiting
Casa Colina Entity and on our Internet site at www.casacolina.org . You also may obtain any new notice by contacting the Privacy Office.
VII. Privacy Office
You may contact the Privacy Office at:
Casa Colina Centers for Rehabilitation
255 E. Bonita Avenue
Pomona, CA 91769-6001
Telephone Number: 909/596-7733, Ext. 3410
Copyright 2002 McDermott, Will & Emery