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This notice describes “How Information About You May Be Used and Disclosed and Also How You Can Get Access to This Information”. Please review it carefully.
1. Federal and State law provides you with certain basic rights and protections in connection with the information we maintain about you. Beverly Hospital is required by law to maintain the privacy of your information and to provide you with notice of privacy practices. This notice summarizes your rights and Beverly Hospital’s duties with respect to your information. It also describes how Beverly Hospital's personnel may use and disclose your information. Finally, it describes the complaint process for you to follow if you believe your privacy rights have been violated. If you have any questions about this notice or your rights relating to your information, please contact Beverly Hospital's HIPAA Compliance Officer/Privacy Officer at:
309 W. Beverly Blvd.
Montebello, CA 90640
Attn: Health Insurance Portability and Accountability Act (HIPAA)
HIPAA Compliance Officer/Privacy Officer
Privacy (323) 837-5120
Facsimile (323) 837-3414
2. We are required to follow the terms of this Notice of Beverly Hospital’s Privacy Practices as it is currently in effect. We have the right to change the terms of this notice, and to make the new notice effective for all health information we maintain. If we change the notice, we will post an updated copy of it in our facilities and on our website, and make it available at our service delivery sites.
3. To whom does this notice apply? This notice applies to all persons providing services to you at the following sites:
a. Beverly Hospital
b. 101 Building
c. 105 Building
d. Center for Wound Care and Hyperbaric Medicine
e. Kelpien Center/Women’s Care Center/CPSP Clinic
4. This notice applies to services provided to you at these sites by Beverly Hospital, and by independent members of our Medical Staff. We may share health information about you with these providers for the purpose of providing services to you and operating our facilities.
B. Your Rights Regarding Information
You have the following rights regarding information we maintain about you.
1. Right to Inspect and Copy
a. You have the right to inspect and copy information about you. Usually, this includes medical and billing records, but does not include psychotherapy notes.
b. To inspect and copy information about you, you must submit your request in writing to Beverly Hospital's Privacy Office.
c. If you request a copy of your information, we may charge a fee for the costs of copying, mailing, and other supplies associated with your request.
d. We may deny all or part of your request to inspect and copy your information in certain very limited circumstances. If you are denied access to your information, you may, under certain circumstances, request that such denial be reviewed. Any such review will be conducted by a licensed healthcare professional chosen by Beverly Hospital; however, the person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
2. Right to Amend
a. If you feel that any of the information we have about you is incorrect or incomplete, you may ask us to amend such information. You have the right to request an amendment for as long as the information is kept by or for us.
b. To request an amendment, your request must be made in writing and submitted to Beverly Hospital's Privacy Office.
c. In addition, you must provide a reason that supports your request.
d. 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:
(1) Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
(2) Is not part of the information kept by or for Beverly Hospital.
(3) Is not part of the information which you would be permitted to inspect and copy.
(4) Is accurate and complete.
(5) If we deny the requested amendment, you have the right to submit a written statement disagreeing with the denial or, alternatively, you may request Beverly Hospital to provide your request for amendment and the denial with any future disclosures of the information.
3. Right to an Accounting of Disclosures
a. You have the right to the receiving and accounting of certain disclosures of your information made by us in the six years prior to the date on which the accounting is requested, starting from April 14, 2003 (the compliance date of the HIPAA Privacy Standards). Such right to accounting; however, does not extend to disclosures made to you, pursuant to an authorization, incident to a use or disclosure otherwise permitted or required, for treatment, payment and healthcare operations, for the patient directory, to family members or friends involved in your care, for notification purposes, for national security of intelligence purposes, to correctional institutions or law enforcement Officers in custodial situations, or as part of a limited data set in accordance with applicable law.
b. To request an accounting of disclosures to which you are entitled, you must submit your request in writing to Beverly Hospital's Privacy Office.
c. Your request must state a time period, which may not be longer that six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within any consecutive 12-month period will be free. For additional lists, we may charge you for the costs associated with providing the list. If we intend to charge a fee, we will notify you of the estimated cost involved and will give you an opportunity to withdraw or modify your request before any costs are incurred.
4. Right to Request Restrictions
a. You have the right to request restrictions or limitations on the information we use or disclose about you for treatment, payment of healthcare operations. You also have the right to request a limit on the 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). For example, you could ask that we not use or disclose information to a relative about a surgery you had.
b. Although 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. A restriction agreed to by Beverly Hospital is not effective to prevent uses or disclosures permitted or required under Section C below (excluding treatment, payment, and health care operations).
c. Your request for restrictions should be made in writing to
Beverly Hospital's Privacy Office.
d. In your request, you should tell us:
(1) What information you want to limit
(2) Whether you want to limit our use, disclosure, or both
(3) To whom you want the limits to apply (for example, disclosures to your spouse, relative, and etc.)
5. Right to Request Confidential Communications
a. You have the right to request that we communicate with you about 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. Any such request must be made in writing to Beverly Hospital's Privacy Office.
b. You must specify how or where you wish to be contacted. We will not ask you the reason for your request and will accommodate all reasonable requests.
6. Right to Receive a Copy of This Notice
a. You have the right to receive 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 at our website, www.Beverly.org, or by contacting Beverly Hospital's Privacy Office.
C. How We May Use and Disclose Information About You
Uses and Disclosures of Information That Do Not Require Your Consent or Authorization
The following are examples of the types of uses and disclosures of your protected information that Beverly Hospital is permitted or required by law to make without your consent or authorization.
To provide you with treatment or services, we may need to use or disclose information about you to doctors, nurses, technicians, students, or other Beverly Hospital personnel who are involved in your treatment. For example, a doctor may need to know what drugs you are allergic to before prescribing medications. Departments within Beverly Hospital may share information about you to coordinate your care. For instance, the Laboratory may request information to complete Laboratory work. We may also disclose information about you to people who may be involved in your medical care after you leave Beverly Hospital, such as home health agencies and (unless you object) family members and friends involved in your care.
We may use and disclose your information for Beverly Hospital to bill and receive payment for the treatment that you received here. For example, we may use or disclose your information to your insurance company about a service you received at Beverly Hospital so that your insurance company can pay us or reimburse you for the service. We may also ask your insurance company for prior authorization for a service to determine whether the insurance company will cover it.
3. Healthcare Operations
We may use and disclose information about you for our internal operations. These include uses and disclosures that are necessary to run Beverly Hospital and make sure that our patients receive quality care. For example, we may use or disclose information about you to evaluate our staff’s performance in caring for you. Information about you and other patients may also be combined to allow us to evaluate whether we should offer additional services or discontinue other services and whether certain treatments are effective. We may also aggregate this information with other health care providers to evaluate whether we can make improvements in the care and services that we offer. To best protect your privacy when we are aggregating information with other providers, we will remove information that identifies you.
We also disclose health information to our contractors and agents who assist us in these functions, but we obtain a confidentiality agreement from them before we make such disclosures for payment or operational purposes.
5. Required by Law
We may use or disclose your information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
6. Public Health
We may disclose your protected information for public health activities and purposes to a public health authority who is permitted by law to collect or receive the information for the purpose of preventing or controlling disease, injury, or disability (e.g. reporting of disease, injury, vital elements such as birth or death, public health surveillance or investigations, and etc.). We may also use or disclose your information, if directed by the public health authority, to an Officer of a foreign government agency that is collaborating with the public health authority.
7. Food and Drug Administration
We may disclose your information to a person/company subject jurisdiction of the U.S. Food and Drug Administration (FDA) with respect to a FDA-regulated product or activity for which that person/company has responsibility, for the purpose of activities related to the quality, safety or effectiveness of such product or activity. Such purposes include to collect or report adverse events, product defects or problems, or biologic product deviations; to track FDA-regulated products; to enable product recalls, repairs or replacement, or look back (including locating and notifying individuals who have received such products); or to conduct post marketing surveillance.
8. Communicable Diseases
We may disclose your information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
9. Abuse or Neglect
We may disclose your information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your information if we believe that you have been a victim of abuse, neglect, or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable Federal and State laws.
10. Health Oversight
We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs, and civil rights laws.
11. Judicial and Administrative Proceedings
We may disclose your information in the course of a judicial or administrative proceeding in response to an order of a court or administrative tribunal. We may also disclose your information in response to a subpoena, discovery request, or other lawful process, but only if reasonable efforts have been made to notify you of the request or to obtain a protective order limiting the use of the information to the litigation or proceeding for which it was requested.
12. Law Enforcement
We may also disclose information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include:
a. Legal processed and as otherwise required by law
b. Limited information requests for identification and location purposes
c. Pertaining to victims of a crime
d. Suspicion that death has occurred as a result of criminal conduct
e. In the event that a crime occurs on the premises of
f. Medical emergency (not on the Beverly Hospital's premises) and it is likely that a crime has occurred.
13. Coroners, Funeral Directors, and Organ Donation
We may disclose information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, consistent with applicable law, in order to permit the funeral director to carry out his or her duties. We may disclose such information in reasonable anticipation of death. Information may be used or disclosed to organ procurement organizations or other entities engaged in the procurement, banking, or transportation of cadaveric organs, eyes, or tissue for the purposes of facilitating organ, eye or tissue donation and transplantation.
We may disclose your information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
15. Serious Threat to Health or Safety
Consistent with applicable federal and state laws, we may disclose your information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose information, if it is necessary for law enforcement authorities to identify or apprehend an individual because of a statement by the individual admitting participation in a violent crime that Beverly Hospital reasonably believes may have caused serious physical harm to the victim or where it appears from all the circumstances that the individual has escaped from a correctional institution or from lawful custody.
16. Military Activity and National Security
When the appropriate conditions apply, we may use or disclose information of individuals who are Armed Forces personnel:
a. For activities deemed necessary by appropriate military command authorities
b. For the purpose of a determination by the Department of Veteran Affairs of your eligibility for benefits
c. To foreign military authority, if you are a member of that foreign military service. We may also disclose your information to authorized federal Officers for conducting national security and intelligence activities, including the provision of protective services to the President of others legally authorized.
17. Worker's Compensation
Your information may be disclosed by us as authorized to comply with worker's compensation laws and other similar legally established programs.
If you are an inmate of a correctional institution or under the custody of a law enforcement Officer, we may release information about you to the correctional institution or law enforcement Officer. This release would be necessary:
a. For the institution to provide you with healthcare
b. To protect your health and safety or the health and safety of others
c. For the safety and security of the correctional institution
19. Required Uses and Disclosures
Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the law and regulations.
20. Appointment Reminders
We may use and disclose information to contact you as a reminder that you have an appointment for treatment or medical care at Beverly Hospital.
21. Treatment Alternatives
We may use and disclose information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
22. Health-Related Benefits and Services
We may use and disclose information to tell you about
health-related benefits or services that may be of interest to you.
We may contact you to raise funds for our organization. We will give you the opportunity to opt out of receiving fundraising communications.
D. Uses and Disclosures to Which You Have the Opportunity to Object
We may use or disclose your information for any of the purposes described in this section unless you affirmatively object to or otherwise restrict a particular release.
Please direct any written objections or restrictions to Beverly Hospital's Privacy Office.
1. Patient Directory
Unless you object, we may include certain limited information about you in the patient directory while you are a patient. This information may include your name, location in Beverly Hospital, your general condition (e.g., fair, stable, and etc.) and may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they do not ask for you by name. This is so your family, friends and clergy can visit you in Beverly Hospital and generally know how you are doing.
2. Others Involved in Your Care
Unless you object, we may disclose information to a friend or family member who is involved in your care, to the extent we judge necessary for their participation.
1. In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described above. In particular, there are special restrictions on disclosure of the following kinds of health information:
a. Information obtained the course of providing services under
state-funded mental healthcare programs.
b. Information obtained the course of providing services under
state-funded services to the developmentally disabled.
c. Information obtained the course of providing services under state and federally-funded drug and alcohol abuse treatment and referral programs.
d. Information relating to HIV testing.
e. Psychotherapy notes
2. We will comply with these restrictions in our use of your health information.
Except as described above, we will not permit other uses and disclosures of your health information without your written authorization, which you may revoke at any time in the manner described in our authorization form.
G. Contact and Complaint Information
You have the right to file a complaint with our Privacy Officer if you believe your privacy rights have been violated. You must provide us with specific, written information to support your complaint. You may also file a complaint with the Office for Civil Rights of the U.S. Secretary of Health and Human Services. We will not retaliate against you in any way for filing a complaint.
Questions, comments, complaints and requests regarding the matters described in this notice should be directed to the following:
309 W. Beverly Blvd.
Montebello, CA 90640
Attn: Health Insurance Portability and Accountability Act (HIPAA)
HIPAA Compliance Officer/Privacy Officer
Privacy (323) 837-5120
Facsimile (323) 837-3414