Patient Privacy Notice

Joint Notice of Privacy Practices for Health Information

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.

Who will follow the practices outlined in this notice?
Community Hospital of San Bernardino provides health care to our patients in partnership with physicians, health care providers, and other professionals and organizations in an organized health care arrangement (hereinafter referred to as we, our or us).  This is a joint notice of our information privacy practices.  The practices in this notice will be followed by:

• Any health care professional who participates in an organized health care arrangement with us to assist in providing treatment to you.  These professionals may include, but are not limited to, physicians, allied health professionals, and other licensed health care professionals;
• All departments and units of our organization, including skilled nursing, home health, clinics, outpatient services, mobile units, hospice, and emergency department; and
• Our employees, staff and volunteers, including regional support offices and affiliates.

Our pledge to you:
We understand that medical information about you is private and personal, and we are committed to protecting it.  Each time you visit a hospital, physician or other healthcare provider, a record of your visit is made.  This notice applies to the records of your care at Community Hospital of San Bernardino, whether created by facility staff or your personal physician.  Other health care providers providing treatment to you may have different practices or notices regarding their use and disclosure of medical information about you maintained in their own offices or clinics.
 
We will:

• Keep medical information about you private, as provided by law;
• Provide, or make available, as applicable, this notice of our legal duties and privacy practices for medical information about you; and
• Follow the terms of the notice that is currently in effect.

Changes to this Notice:
We may change our practices from time to time.  Changes will apply to medical information we already hold, as well as new information after the change occurs.  If we make a significant change in our practices, we will change our notice and post the new notice in prominent locations in our facilities and on our Web site at: www.chw.edu/privacy.  Even though you may have agreed to receive this notice electronically, you can request a paper copy of the notice currently in effect at any time by sending a note to Community Hospital of San Bernardino, Facility Privacy Office.  We will also offer you a paper copy of the notice, if it has changed, the next time you register for treatment with us.

How we may use and disclose medical information about you:
We will share medical information about you for purposes of treatment (such as sending medical information about you to your physician or to a specialist as part of a referral); to obtain payment for treatment (such as submitting information that identifies you and your diagnosis to a payer or Medicare); and to support health care operations (such as using information about you to assess the quality of care we have provided, utilization and patient satisfaction review). 

We may use health information about you without your prior permission for several other reasons.  Subject to applicable law, we may give out medical information about you to other persons or entities to carry out their duties for (a) public health purposes (such as, births, deaths, public health surveillance); (b) abuse, neglect or domestic violence reporting; (c) health oversight audits or inspections; (d) research studies; (e) coroners or medical examiner services; (f) funeral arrangements; (g) organ donation; (h) tracking of FDA-regulated products, (i) workers’ compensation purposes; (j) emergencies; (k) data de-identification; and (l) data aggregation.  We may also use limited demographic information about you for fundraising or share such data with our fundraising foundation for fundraising purposes, as permitted by law.  We also share medical information with others when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders. 

We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you, or to support fundraising efforts.

If admitted as a patient, unless you tell us otherwise, we may list in the patient directory your name, location in the hospital, your general condition (good, fair, etc.) and your religious affiliation, and will release all but your religious affiliation to anyone who asks about you by name.  Your religious affiliation may be shared only with clergy members, even if they do not ask for you by name.

We may share medical information about you with a friend or family member who is involved in your medical care, with others whom you designate as involved in your medical care, or with disaster relief authorities so that your family can be notified of your location and condition.

Other uses of medical information:
In any other situation not covered by this notice, where we may wish to use or share medical information about you, we will ask for your written permission.  You can later cancel your permission by notifying us in writing.

Your rights regarding medical information about you:
In most cases, when you give us a written request, you have the right to look at or get a copy of medical information that we use to make decisions about your care.  We will give you a form that you can complete to make the request.  If you request copies of the information, however, we may charge a fee for cost of copying, mailing or other related supplies.  If we deny your request to look at the information or get a copy of it, you may give us a written request for a review of that decision. 

If you believe that information in our records about you is incorrect or if important information is missing, you have the right to request that we change the records, by submitting a request in writing and including your reason for requesting the change.  We will provide you a form that you can complete to make the request.  We may deny your request to change a record if the information was not created by us; if it is not part of the medical information kept by us; or if we determine the record is complete and correct.  If we deny your request to change, you may submit a written request to review that denial.

You have the right to make a written request to us for a list of those instances where we have shared medical information about you, other than for treatment, payment, health care operations or where you have specifically given us written permission for the sharing.  Your request must state the time period desired for the listing, which must be less than a 6-year period starting after April 14, 2003.  The first list request in a 12-month period is free; other list requests will be charged according to our cost of producing the list.  We will inform you of the cost when you request the list.

You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by telling us in writing of the specific way or location for us to communicate with you.

You may request, in writing, that we not use or share medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically permitted by you, when required by law, or in an emergency.  We will consider your request but we may not be able to agree to it and we are not legally required to agree to your request.  We will inform you of our decision on your request.

All written requests or requests for review of denials should be submitted to our Facility Privacy Office listed at the bottom of this notice.

Complaints:

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Facility Privacy Office (listed below).  You may also contact our Chief Privacy and Data Security Administrator at (415) 438-5565.  Finally, you may send a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights.  Our Facility Privacy Office can provide you the address.  We will not penalize or retaliate against you for filing a complaint.

Community Hospital of San Bernardino
Privacy Office
185 Berry Street, Suite 300
San Francisco, CA 94107
(415) 438-5565
(415) 591-2436

www.chw.edu/privacy

Version effective November 1, 2003