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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.
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, California.
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:
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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.
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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.
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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 or compliance.
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 Extension 2229.
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 disclosure.
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 or safety.
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 form ("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 authorization:
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 medical emergencies).
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 evaluation activities).
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 in question).
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 privileges.
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 inthe 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 to disclosure).
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 in writing.
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 requirements).
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 definitions).
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 statement.
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 electronically.
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 areas around 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:
Privacy Office
Casa Colina Centers for Rehabilitation
255 E. Bonita Avenue
Pomona, CA 91769-6001
Telephone Number: 909/596-7733, Ext. 3410
E-mail:
privacyofficer@casacolina.org
Copyright 2002 McDermott, Will & Emery
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