SAN GORGONIO MEMORIAL HOSPITAL
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATON. PLEASE REVIEW IT CAREFULLY.
We are committed to protecting the confidentiality of your medical information, and are required by law to do so. This notice describes how we may use your medical information within the Hospital and how we may disclose it to others outside the Hospital. This notice also describes the rights you have concerning your own health information. Please review it carefully and let us know if you have questions.
HOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?
Treatment: We may use your medical information to provide you with medical services and supplies. We may also disclose your medical information to others that need that information to treat you, such as doctors, physician assistants, nurses, medical and nursing students, technicians, therapists, emergency service and medical transportation providers, medical equipment providers, and others involved in your care. For example, we will allow your physician to have access to your Hospital medical record to assist in your treatment at the hospital and for follow-up care.
We also may use and disclose your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about health-related services available to you.
Patient/Resident Directory: In order to assist family members and other visitors in locating you while you are in the Hospital, the Hospital maintains a patient directory. This directory includes your name, room number, your general condition (such as fair, stable, or critical), and your religious affiliation (if any). We will disclose this information to someone who asks for you by name, although we will disclose your religious affiliation only to clergy members. If you do not want to be included in the Hospital's patient directory, please put your statement in writing, giving it to the admissions clerk.
Family Members and Others Involved in Your Care: We may disclose your medical information to a family member or friend who is involved in your medical care, or to someone who helps to pay for your care. We also may disclose your medical information to disaster relief organizations to help locate a family member or friend in a disaster. If you do not want the Hospital to disclose your medical information to family members or others who will visit you, please notify the person admitting you and also your nurse in writing.
Payment: We may use and disclose your medical information to get paid for the medical services and supplies we provide to you. For example, your health plan or health insurance company may request to see parts of your medical record before they will pay us for your treatment.
Hospital Operations: We may use and disclose your medical information if it is necessary to improve the quality of care we provide to patients or to run the Hospital. We may use your medical information to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning. For example, we may look at your medical record to evaluate whether Hospital personnel, your doctors, or other health care professionals did a good job.
Many of our patients like to make contributions to the Hospital. The Hospital or its foundation may contact you in the future to raise money for the Hospital. If you do not want the Hospital or its foundation to contact you for fundraising, please notify the Foundation Office in writing.
Research: We may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information.
Required by Law: Federal, state, or local laws sometimes require us to disclose patients' medical information. For instance, we are required to report child abuse or neglect and must provide certain information to law enforcement officials in domestic violence cases. We also are required to give information to the Workers' Compensation Program for work-related injuries.
Public Health: We also may report certain medical information for public health purposes. For instance, we are required to report births, deaths, and communicable diseases to the State of California We also may need to report patient problems with medications or medical products to the FDA, or may notify patients of recalls of products they are using.
Public Safety: We may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, and to report criminal conduct at the hospital. We also may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety.
Health Oversight Activities: We may disclose medical information to a government agency that oversees the Hospital or its personnel, such as the; California Department of Health Services, the federal agencies that oversee Medicare, the Board of Medical Examiners or the Board of Nursing. These agencies need medical information to monitor the Hospital's compliance with state and federal laws.
Coroners, Medical Examiners and Funeral Directors: We may disclose medical information concerning deceased patients to coroners, medical examiners and funeral directors to assist them in carrying out their duties.
Organ and Tissue Donation: We may disclose medical information to organizations that handle organ, eye or tissue donation or transplantation.
Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed forces, we may release your medical information as required by military command authorities or to the Department of Veterans Affairs. The Hospital may also disclose medical information to federal officials for intelligence and national security purposes, for presidential Protective Services, or to the Department of State for its security clearances.
Judicial Proceedings: The Hospital may disclose medical information in a lawsuit if the Hospital is ordered to do so by a court or if the Hospital receives a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations to that you will have a chance to object to sharing your medical information.
Information with Additional Protection: Certain types of medical information have additional protection under state or federal law. For instance, medical information about communicable disease and HIV/AIDS, drug and alcohol abuse treatment, genetic testing, and court-ordered mental evaluation is treated differently than other types of medical information. For those types of information, the Hospital is required to get your permission before disclosing that information to others in most circumstances.
Other Uses and Disclosures: If the Hospital wishes to make a use or disclosure of your medical information for a purpose that is not discussed in this Notice, the Hospital will seek your permission. If you give your permission to the Hospital, you may take back that permission any time, unless we have already relied on your permission to use or disclose the information.
WHAT ARE YOUR RIGHTS?
Right to Request Your Medical Information: You have the right to look at your own medical information and to get a copy of that information. (The law requires us to keep the original record.) This includes your medical record, your billing record, and other records we use to make decisions about your care. To request your medical information, submit a written request to the Medical Records Department. If you request a copy of your information, we will charge you for our costs to copy the information. We will tell you in advance what this copying will cost. You can look at your record at no cost.
Right to Request Amendment of Medical Information You Believe Is Erroneous or Incomplete: If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record. To make a request to amend your medical information, submit a written request to the Privacy Officer.
Right to Get a List of Certain Disclosures of Your Medical Information: You have the right to request a list of many of the disclosures we make of your medical information. If you would like to receive such a list, submit a written request to Privacy Officer. We will provide the first list to you free, but we may charge you for any additional lists you request during the same year. We will tell you in advance what this list will cost.
Right to Request Restrictions on How the Hospital Will Use or Disclose Your Medical Information for Treatment, Payment, or Health Care Operations: You have the right to request us not to make uses or disclosures of your medical information to treat you, to seek payment for care, or to operate the Hospital. We are not required to agree to your request, but if we do agree, we will comply with that agreement. If you want to request a restriction, submit your request in writing to the Privacy Officer and describe your request in detail.
Right to Request Confidential Communications: You have the right to request us to communicate with you in a way that you feel is more confidential. For example, you can ask us not to call your home, but to communicate only by mail. To do this, submit your request in writing to Privacy Officer at the hospital address. You can also ask to speak with your health care providers in private outside the presence of other patients-just ask them!
Right to a Paper Copy: While you have received this notice electronically, you have the right to a paper copy at any time. You may download a paper copy of the notice from our Web site, at www.sgmh.org, or you may obtain a paper copy of the notice at Registration.
CHANGES TO THIS NOTICE
From time to time, we may change our practices concerning how we use or disclose patient medical information, or how we will implement patient rights concerning their information. We reserve the right to change this notice and to make the provisions in our new notice effective for all medical information we maintain. If we change these practices, we will publish a revised Notice of Privacy Practices. You can get a copy of our current notice of Privacy Practices at any time. The Notice is being made available to our patients at our Web site www.sgmh.org.
WHICH HEALTH CARE PROVIDERS ARE COVERED BY THIS NOTICE?
This Notice of Privacy Practices applies to the Hospital and its personnel, volunteers, students, and trainees. The notice also applies to other health care providers that come to the Hospital to care for patients, such as physicians, physician assistants, therapists, other health care providers that are not employed by the Hospital, emergency service providers, medical transportation companies, and medical equipment and suppliers that come to the hospital. These health care providers will follow this notice for information they receive about you from the Hospital. These other health care providers may follow different practices at their own offices or facilities.
DO YOU HAVE CONCERNS OR COMPLAINTS
Please tell us about any problems or concerns you have with your privacy rights or how the Hospital uses or discloses your medical information. If you have a concern, please contact Privacy Officer.
If for some reason the Hospital cannot resolve your concern, you may also file a complaint with the federal government. To file a complaint against the Hospital, contact:
Department of Health & Human Service Office For Civil Rights
90 7th Street
San Francisco, CA 94103
Fax (415) 437-8329
We will not penalize you or retaliate against you in any way for filing a complaint with the federal government.
DO YOU HAVE QUESTIONS?
The Hospital is required by law to give you this notice and to follow terms of the notice that is currently in effect. If you have any questions about this notice, or have further questions about how the Hospital may use and disclose your medical information, please contact the Privacy Officer at ext. 2166 Monday thru Friday and after hours to the house supervisor.
Effective date: April 14, 2003
SAN GORGONIO MEMORIAL HOSPITAL
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