Notice of Privacy Practices Statement
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 Presents this Notice
This Notice describes the privacy practices of Brotman Medical Center (the "Hospital"),
as well as the physician members of its workforce, the physician members of the
medical staff, and allied health professionals who practice at the Hospital. The
Hospital and the individual health care providers together are sometimes called
"the Hospital and Health Professionals" in this Notice. While the Hospital and Health
Professionals engage in many joint activities and provide services in a clinically
integrated care setting, the Hospital and Health Professionals each are separate
legal entities. This Notice applies to services furnished to you at Brotman Medical
Center as a Hospital inpatient or outpatient or any other services provided to you
in a Hospital-affiliated program involving the use or disclosure of your health
information.
II. Privacy Obligations
The Hospital and Health Professionals are required by law to maintain the privacy
of your health information ("Protected Health Information" or "PHI") and to provide
you with this Notice of legal duties and privacy practices with respect to your
Protected Health Information. When the Hospital and Health Professionals use or
disclose your Protected Health Information, the Hospital and Health Professionals
are required to abide by the terms of this Notice (or other notice in effect at
the time of the use or disclosure). Special privacy obligations, described in Section
IV.D, apply to you if you are admitted to the Hospital's psychiatric unit or chemicaldependency
treatment center.
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which are described in Section IV below, your written authorization
must be obtained in order to useand/or disclose your PHI. However, the Hospital
and Health Professionals 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.
Your PHI, but not your "Highly Confidential Information" (defined in Section IV.C
below), may be used to treat you, obtain payment for services provided to you and
conduct "health care operations" as detailed below:
- Treatment. Your PHI may be used and disclosed to provide treatment and other services
to you--for example, to diagnose and treat your injury or illness. In addition,
you may be contacted to provide you appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest
to you. Your PHI may also be disclosed to other providers involved in your treatment.
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Payment. Your PHI may be used and disclosed to obtain payment for services provided
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. Your PHI may be used and disclosed for health care operations,
which include internal administration and planning and various activities that improve
the quality and cost effectiveness of the care delivered to you. For example, PHI
may be used to evaluate the quality and competence of physicians, nurses and other
health care workers. PHI may be disclosed to the Hospital Privacy Office in order
to resolve any complaints you may have and ensure that you have a comfortable visit.
Your PHI also may be disclosed 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. In addition, PHI may be
shared with business associates who perform treatment, payment and health care operations
services on behalf of the Hospital and Health Professionals.
B. Use or Disclosure for Directory of Individuals in the Hospital. The Hospital
may include your name, location in the Hospital, general health condition and religious
affiliation in a patient directory without obtaining your authorization unless you
object to inclusionin the directory or are located in a specific ward, wing or unit
the identification of which would reveal that you are receiving treatment for (1)
mental health and developmental disabilities; (2) alcohol and drug abuse; (3) HIV/AIDS;
(4) communicable disease(s); (5) genetic testing; (6) child abuse and neglect; (7)
domestic and elder abuse or (8) sexual assault. 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. Your PHI
may be disclosed 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 (1) your agreement is obtained; (2) you do not object
to the disclosure after being provided an opportunity to object; or (3) it can be
reasonably inferred 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,
the Hospital and Health Professionals may exercise professional judgment to determine
whether a disclosure is in your best interests. If information is disclosed to a
family member, other relative or a close personal friend, the Hospital and Health
Professionals would disclose only information believed to be directly relevant to
the person's involvement with your health care or payment related to your health
care. Your PHI also may be disclosed in order to notify (or assist in notifying)
such persons of your location or general condition.
D. Public Health Activities. Your PHI may be disclosed 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.
E. Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed
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
if there is a reasonable belief that you are a victim of abuse, neglect or domestic
violence.
F. Health Oversight Activities. Your PHI may be disclosed 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.
G. Judicial and Administrative Proceedings. Your PHI may be disclosed in
the course of a judicial or administrative proceeding in response to a legal order
or other lawful process.
H. Law Enforcement Officials. Your PHI may be disclosed 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.
I. Decedents. Your PHI may be disclosed to a coroner or medical examiner
as authorized by law.
J. Organ and Tissue Procurement. Your PHI may be disclosed to organizations
that facilitate organ, eye or tissue procurement, banking or transplantation.
K. Research. Your PHI may be disclosed without your consent or authorization
if an Institutional Review Board approves a waiver of authorization for disclosure.
L. Health or Safety. Your PHI may be disclosed to prevent or lessen a serious
and imminent threat to a person's or the public's health or safety.
M. Specialized Government Functions. Your PHI may be disclosed to units of
the government with special functions, such as the U.S. military or the U.S. Department
of State under certain circumstances.
N. Workers' Compensation. Your PHI may be disclosed as authorized by and
to the extent necessary to comply with California law relating to workers' compensation
or other similar programs.
O. As Required by Law. Your PHI may be disclosed 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, your PHI may be used or disclosed only
when you provide your written authorization on an authorization form ("Your Authorization").
For instance, you will need to execute an authorization form before PHI can be sent
to your life insurance company or to the attorney representing the other party in
litigation in which you are involved.
B. Marketing. Your written authorization ("Your Marketing Authorization")
also must be obtained prior to using your PHI to send you any marketing materials.
(However, marketing materials can be provided you in a face-to-face encounter without
obtaining Your Marketing Authorization. The Hospital and Health Professionals are
also permitted to give you a promotional gift of nominal value, if they so choose,
without obtaining Your Marketing Authorization.) In addition, the Hospital and Health
Professionals 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, treatment, and referral; (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 your Highly Confidential Information to be
disclosed for a purpose other than those permitted by law, your written authorization
is required.
D. Use and Disclosure of Information Upon Admission to a Psychiatric Unit or Chemical
Dependency Treatment Center. Information regarding your care in the Hospital
and Health Professionals psychiatric unit or chemical dependency treatment center
is subject to special protections under state and federal law. The terms of this
Notice shall apply to your PHI unless otherwise described in this Section IV.D.
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Psychiatric Treatment. Your PHI will be disclosed to Hospital personnel and other
qualified mental health professionals who have medical or psychological responsibility
for your treatment, or in the course of a conservatorship proceeding. Your Authorization
will be obtained prior to disclosing your PHI to other treatment providers who do
not have medical or psychological responsibility for your care. To the extent necessary,
your PHI will also be disclosed to obtain payment for services rendered to you,
as for example, to your insurance company. On occasion, your PHI may be used for
health care operations but, to the extent possible, your personally identifiable
information will be removed.
Reasonable attempts will be made to notify your next of kin or any other person
designated by you of your admittance for inpatient care, your release, transfer,
serious illness or injury, unless you object to such disclosures. Your PHI will
not be disclosed to your family members or any other person designated by you seeking
information about your diagnosis, prognosis, medications and your progress unless
your written Authorization is obtained. The Hospital and/or Health Professionals
will not respond to other inquiries about your treatment and will not disclose information
revealing that you are a patient of the psychiatric unit to other unauthorized individuals
who call the Hospital to seek information without your written Authorization. If
you are a minor or have a personal representative (such as a guardian or person
authorized under a power of attorney), the Hospital and/or Health Professionals
will consult with you prior to sharing information with such person. If you refuse
to grant permission or are unable to grant permission, information may be shared
with your personal representative only to the extent permitted or required by state
law.
The Hospital and/or Health Professionals will comply with California law in reporting
your PHI for public health activities or health oversight activities. If you disclose
information related to child abuse or other types of actual or threatened abuse,
such information may be reported to governmental authorities responsible to investigate
such abuse. If you commit a crime on the premises, your PHI may be used to report
the crime. To the extent possible, the Hospital and/or Health Professionals will
notify you or seek a protective order prior to disclosing information to a judicial
proceeding. Your PHI will not be used for marketing.
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Chemical Dependency Treatment. If you are a recipient of chemical dependency treatment,
your PHI is protected by federal confidentiality laws (42 U.S.C. 290dd-3, 290ee-3
and 42 CFR Part 2) and California law. Violations of these laws is a crime and may
be reported to appropriate authorities. Your PHI will be disclosed to Hospital personnel
within the chemical dependency treatment program and certain organizations providing
services to the program that have a need to know your PHI to perform their job duties
or to medical personnel in the event of a medical emergency. Your authorization
will be obtained prior to disclosing any PHI to obtain payment for services rendered
to you, such as for example, to your insurance company. On occasion, your PHI may
be used for health care operations but your identifying information will be removed.
The Hospital and/or Health Professionals will not respond to inquiries about your
treatment and will not disclose information revealing that you are a patient of
the chemical dependency center to unauthorized individuals who call the Hospital
to seek information. If you are twelve years of age or older, your PHI will not
be disclosed to a family member, relative or any other person seeking information
about your care without your written Authorization, except as permitted or required
by state law.
If you are a minor twelve years of age or younger or have a personal representative
(such as a guardian or person authorized under a power of attorney), you will be
consulted prior to sharing information about your care. If you refuse to grant permission
or are unable to grant permission, information may be shared with your personal
representative only to the extent permitted or required by state law. The Hospital
and Health Professionals will comply with federal and California law in reporting
your PHI for public health activities or health oversight activities. If you disclose
information related to child abuse, the Hospital and Health Professionals may be
required to report such information to governmental authorities responsible to investigate
such abuse. If you commit a crime on the premises your PHI may be used to report
the crime. To the extent possible the Hospital and/or Health Professionals will
notify you or seek a protective order prior to disclosing information to a judicial
proceeding. Your PHI will not be used for marketing.
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 your privacy rights have been violated
or disagree with a decision made about access to your PHI, you may contact the Hospital
Privacy Office. You may also file written complaints with the Director, Office for
Civil Rights of the U.S. Department of Health and Human Services. Upon request,
the Hospital Privacy Office will provide you with the correct address for the Director.
The Hospital and Health Professionals will not retaliate against you if you file
a complaint with the Hospital Privacy Office or the Director.
B. Right to Request Additional Restrictions. You may request restrictions
on the 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 thenotification of such individuals
regarding your location and general condition. While all requests for additional
restrictions will be carefully considered, the Hospital and Health Professionals
are not required to agree to a requested restriction. If you wish to request additional
restrictions, please obtain a request form from the Hospital Privacy Office and
submit the completed form to the Hospital Privacy Office. A written response will
be sent to you.
C. Right to Receive Confidential Communications. You may request, and the
Hospital and Health Professionals 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 the Hospital
and Health Professionals have taken action in reliance upon it, by delivering a
written revocation statement to the Hospital Privacy Office identified below.
E. Right to Inspect and Copy Your Health Information. You may request access
to your medical record file and billing records maintained by the Hospital and Health
Professionals in order to inspect and request copies of the records. Under limited
circumstances, you may be denied access to a portion of your records. You should
take note that, if you are a parent or legal guardian of a minor, certain portions
of the minor¯s medical record will not be accessible to you (for example, records
pertaining to health care services for which the minor can lawfully give consent
and therefore for which the minor has the right to inspect or obtain copies of the
record (i.e. abortion or mental health treatment); or the health care provider determines,
in good faith, that access to the patient records requested by the representative
would have a detrimental effect on the provider's professional relationship with
the minor patient or on the minor's physical safety or psychological well-being.
If you desire access to your records, please obtain a record request form from the
Hospital Privacy Office and submit the completed form to the Hospital Privacy Office.
If you request copies, you will be charged the reasonable cost of copies in accordance
with federal and state law. You also will be charged for the postage costs,if you
request that the copies be mailed to you.
F. Right to Amend Your Records. You have the right to request that PHI maintained
in your medical record file or billing records be amended. If you desire to amend
your records, please obtain an amendment request form from the Hospital Privacy
Office and submit the completed form to the Hospital Privacy Office. Your request
will be accommodated unless the Hospital and Health Professionals 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 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, you will
be charged $10.00 for 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 December 8, 2003.
B. Right to Change Terms of this Notice. The terms of this Notice may be
changed at any time. If this Notice is changed, the new notice terms may be made
effective for all PHI that the Hospital and Health Professionals maintain, including
any information created or received prior to issuing the new notice. If this Notice
is changed, the new notice will be posted in waiting areas around the Hospital and
on the Hospital¯s Internet Site at www.brotmanmedicalcenter.com. You also may obtain
any new notice by contacting the Hospital Privacy Office.
VII. Privacy Office
You may contact the Hospital Privacy Office at:
Privacy Office
Brotman Medical Center
3828 Delmas Terrace
Culver City, CA 90231-2459
Telephone: (310) 836-7000 x1222