| |  |
NOTICE OF INFORMATION/PRIVACY PRACTICESEsta forma está disponible
en Español THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this
notice, please contact the Director of Quality Assurance and Medical Records at
(408) 364-4122. OUR PLEDGE REGARDING PRIVATE HEALTH INFORMATION:
We understand that the information we maintain about you and your health is personal.
We are committed to protecting this information. We create a record of the care
and services you receive at EMQ. We need this record to provide you with quality
care and to comply with certain legal requirements. This notice applies to all
of the records of your care generated by or available to EMQ's workforce (which
may include any health care professional who enters information into your health
care record, volunteers, finance staff, information services staff, etc.). This
notice will tell you about the ways in which we may use and disclose health information
about you. We also describe your rights and certain obligations we have regarding
the use and disclosure of health information. We are required by law to:
- make sure that clinical information that identifies you is kept private;
- give
you this notice of our legal duties and privacy practices with respect to clinical
information about you; and
- follow the terms of the notice that is currently
in effect.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical
and/or clinical information. For each category of uses or disclosures we will
explain what we mean and try to give some 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 clinical/medical information about you to provide you
with treatment or services. We may disclose clinical/medical information about
you to doctors, nurses, clinicians, interns, MATs, or other EMQ personnel who
are involved in treating you. For example, a clinician treating you for an anger
disorder may need to know if you have physically acted out in the past. With this
knowledge the treatment team may create a safety plan to protect you and the people
around you when/if you or your child begin to act out. In addition, the clinician
may need to tell a physician if your symptoms are not improving. The physician
may explore prescribing medication or recommend testing. Different departments
of EMQ may share information about you in order to coordinate the different things
you need, such as food, additional treatment, and medical attention. We also may
disclose information about you to people outside EMQ who may be involved in your
treatment, or as a part of coordinating follow up care. These people may include
family members, social workers, school employees, neighbors, clergy, county employees,
or others involved in providing services that are part of your care.
- For
Payment. We may use and disclose medical/clinical information about you so
that the treatment and services you receive at EMQ may be billed to and payment
may be collected from you, the county, an insurance company, or a third party.
For example, we may need to give your health plan information about treatment
you received at EMQ so your health plan will pay us or reimburse you for the treatment.
We may also tell your health plan about treatment we are recommending, to obtain
prior approval or to determine whether your plan will cover the treatment.
- For
Health Care Operations. We may use and disclose clinical/medical information
about you for EMQ operations. These uses and disclosures are necessary to run
EMQ and make sure that all of our children & families receive quality care.
For example, we may use clinical/medical information to review our treatment and
services and to evaluate the performance of our staff in caring for you. We may
also combine clinical/medical information about many EMQ clients to decide what
additional services EMQ should offer, what services are not needed, and whether
certain programs are effective. We may also disclose information to doctors, nurses,
interns, clinicians, and other EMQ personnel for review and learning purposes.
We may provide information to representatives of organizations with responsibility
for compliance, licensure, quality of care, and funding purposes.
- Reminders.
We may use and disclose clinical/medical information to contact you as a reminder
that you have/had an appointment to receive services at EMQ.
- Treatment
Alternatives. We may use and disclose clinical/medical information to tell
you about or recommend possible treatment options or alternatives that may be
of interest to you.
- Health-Related Benefits and Clinical Services.
We may use and disclose medical/clinical information to tell you about health-related
benefits or services that may be of interest to you.
- Fundraising Activities.
We may use clinical/medical information about you to contact you in an effort
to raise money for EMQ and its operations. We only would release contact information,
such as your name, address and phone number and the dates you received treatment
or services at EMQ. If you do not want EMQ to contact you for fundraising efforts,
you must notify the Director of Fund Development in writing.
- Individuals
Involved in Your Care or Payment for Your Care. We may release clinical/medical
information about you to a friend or family member who is involved in your clinical/medical
care. We may also give information to someone who helps pay for your care. In
addition, we may disclose clinical/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 clinical/medical information about you for research purposes.
We will always ask for your specific permission if the researcher will have access
to your name, address or other information that reveals who you are, or will be
involved in your care at EMQ.
- Business Associates. There are certain
individuals and/or companies that EMQ hires to perform tasks in lieu of permanent
staff. EMQ has a contract with each individual or company that includes language
to insure that the privacy/confidentiality of each child/family member that EMQ
treats is maintained. As an example, EMQ may hire temporary staff to perform clerical
functions if a permanent staff member is out on medical leave.
THERE
MAY BE OTHER SITUATIONS IN WHICH EMQ WOULD BE REQUIRED AND PERMITTED TO RELEASE
YOUR INFORMATION WITHOUT YOUR AUTHORIZATION OR CONSENT. - As
Required By Law. We will disclose medical information about you when required
to do so by federal, state or local law (for suspected Child Abuse, Elder Abuse,
etc.)
- To Avert a Serious Threat to Health or Safety. We may use and
disclose clinical/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.
- Military and Veterans. If you or your child are now, or
in the future a member of the armed forces, we may release clinical/medical information
about you as required by military command authorities. We may also release clinical/medical
information about foreign military personnel to the appropriate foreign military
authority.
- Workers' Compensation. We may release clinical/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 clinical/medical information about you for public health activities.
These activities generally include the following:
- to prevent or control
disease, injury, condition or disability;
- to report births and deaths;
- to report abuse, neglect, or a victim of violence;
- to report reactions
to medications or problems with products;
- to notify people of recalls of
products they may be using; - Health Oversight Activities. We may disclose
clinical/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 Other Legal Actions. If you are involved
in a lawsuit or a legal action, we may disclose clinical/medical information about
you in response to a court or administrative order or your signed authorization
indicating is it appropriate for us to do so.
- Law Enforcement. We may
release clinical/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 EMQ; 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, Medical Examiners and Funeral Directors. 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 clinical/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 clinical/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 clinical/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 CLINICAL INFORMATION ABOUT YOU.
You have the following
rights regarding medical information we maintain about you: - Right
to Inspect and Copy. You may have the right to inspect and receive copies
of clinical/medical information that may be used to make decisions about your
care. This includes medical and billing records.
To inspect and request
a copy of the clinical & medical information that may be used to make decisions
about you, you must submit your request in writing to the Medical Administrator
(408) 364-4024. 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.
We may also ask you if a summary of your treatment could be provided to you in
lieu of the complete record. If you are denied access to your information, you
may request that the denial be reviewed. Another licensed health care professional
chosen by EMQ will review your request and the denial. The person conducting the
review will be a Clinical Director not involved with the original denial. We will
comply with the outcome of the review.
Records must be maintained for
a period of time consistent with federal and state legislated retention periods.
More detailed information regarding retention is included in EMQ's Policy &
Procedure #1414: "PHI-Information, Retention, & Storage". - Right
to Amend. If you feel that clinical/medical information we have about you
is incorrect or incomplete, you may ask us to amend the information. You have
the right to request an amendment for as long as the information is kept by or
for EMQ.
To request an amendment, your request must be in writing and
submitted directly to the Privacy Officer. Contact the Privacy Officer at (408)
379-3790. 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 accurate and complete.
-
Was not created by us; unless the person or entity that created the information
is no longer available to act on the request to make an amendment;
- Is not
part of the clinical/medical information kept by or for EMQ; and it 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 certain disclosures". This is a list of the disclosures we made of clinical/medical
information about you. We are not required to include disclosures that were made:
for treatment, payment, or healthcare operations, to the individual/legal guardian
regarding their own information, pursuant to an authorization, to person's involved
in the client's care, etc.
To request this list or accounting of certain
disclosures, you must submit your request in writing to the Privacy Officer at
EMQ Children & Family Services, Attn: Privacy Officer, 251 Llewellyn Ave.,
Campbell, CA 95008. Your request must state a time period, which may not be longer
than six years and may not include dates before April 14, 2003. The first list
you request within a 12-month period will be free. For additional lists, you will
be charged 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 Request Restrictions. You have the
right to request a restriction or limitation on the clinical/medical information
we use or disclose about you for treatment, payment or health care operations.
You also have the right to request a limit on the clinical/medical information
we disclose about you to someone who is involved in your care or the payment for
your care, like a family member or friend.
We are not required to agree
to your request. If we do agree, we will comply with your request unless the information
is needed to provide you emergency treatment.
To request restrictions;
contact the Privacy Officer at (408) 379-3790. You must make your request in writing
to: EMQ Children & Family Services, Attn: Privacy Officer, 251 Llewellyn Ave.,
Campbell, CA 95008. In your request, you must tell us (1) what information you
want to limit; (2) whether you want to limit our use, disclosure or both; and
(3) to whom you want the limits to apply, for example, disclosures to your spouse.
- Right to Request Confidential Communications. You have the right to
request that we communicate with you about clinical/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 request confidential communications, you must
make your request in writing to the Privacy Officer at EMQ Children & Family
Services, Attn: Privacy Officer, 251 Llewellyn Ave., Campbell, CA 95008. We will
not ask you the reason for your request. We will accommodate all reasonable requests.
Your request must specify how or where you wish to be contacted. - 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
here.
- To obtain a paper copy of this notice, please call the Privacy Officer at (408)
379- 3790 or mail your request to EMQ Children & Family Services, Attn: Privacy
Officer, 251 Llewellyn Ave., Campbell, CA 95008. At your request, you will be
sent a copy of this notice. 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 clinical/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 all EMQ treatment sites. The notice will contain on the
first page, in the top right-hand corner, the effective date. In addition, each
time you register at or are admitted to EMQ for treatment or health care services
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 EMQ or with the Secretary of
the Department of Health and Human Services. To file a complaint with EMQ, contact
the Director of Quality Assurance and Medical Records at (408) 364-4122 or send
your complaint to: EMQ Children & Family Services
Attn:
Director Quality Assurance & Medical Records
251 Llewellyn Ave.
Campbell,
CA 95008. All complaints must be submitted in writing.
You will not be penalized for filing a complaint. OTHER USES OF CLINICAL/MEDICAL
INFORMATION.
Other uses and disclosures of clinical/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 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. |
