We are required by law to:

(A) Maintain the privacy of your health information, also known as “protected health information” or “PHI;”

(B) Provide you with this Notice, and

(C) Comply with this Notice.

II. Future Changes to Our Practices and This Notice.

We reserve the right to change our privacy practices and to make any such change applicable to the PHI we obtained about you before the change, as well as to information we receive in the future. If a change in our practices is material, we will revise this Notice to reflect the change. You may obtain a copy of any revised Notice by contacting the Privacy Officer, Administration Building, 1500 Bollinger Canyon Road, San Ramon, CA 94583 at (925) 838-6600 or on our website at www.srvfire.ca.gov.

III. How We May Use and Disclose Your Protected Health Information.

The law requires us to obtain your prior authorization for some uses and disclosures. In other circumstances, the law allows us to use or disclose PHI without your authorization. This Section III gives examples of each of these circumstances.

(A) Uses and Disclosures that do not Require Your Authorization. We may use or disclose your PHI to provide treatment to you or in order for others to provide treatment to you. For example, we may disclose your PHI to physicians, nurses, and other health care personnel who are involved in your care.

We may also use or disclose your PHI to your insurance carrier in order to get paid for treatment provided to you. For example, we may use your PHI to create the bills that we submit to the insurance company, or we may disclose certain portions of your PHI to our business associates who perform billing and claims processing or other services for us. We may also disclose your PHI to another health care provider or insurance company for their payment-related activities, such as to get paid for treatment provided to you or to process claims under your health insurance plan.

We may also use or disclose your PHI for our operations related to health care. For example, we may use your PHI to evaluate the quality of care you received from us, or to evaluate the performance of those involved with your care. We may also provide your PHI to our attorneys, accountants and other consultants to make sure we are complying with the laws that affect us. We may also provide your contact information (such as name, address and phone number) and the dates you received services from us, or to a foundation that helps us with our fundraising efforts. In addition, we may also disclose your PHI to another health care provider, health insurance plan or health care clearinghouse for purposes of their operations related to health care. However, we will only do so if they have or have had a relationship with you and if the PHI they request pertains to that relationship. In addition, we will disclose your PHI to these third parties for limited purposes only, such as for them to conduct quality improvement activities, or to review the performance of a health care provider, or for training purposes.

There are stricter requirements for use and disclosure for some types of PHI, for example, drug and alcohol abuse patient information and HIV tests. However, there are still limited circumstances in which these types of information may be used or disclosed without your authorization.

(B) Uses and Disclosures That Require Us to Give You the Opportunity to Object. If you do not object, we may provide relevant portions of your PHI to a family member, friend or other person you indicate is involved in your health care or in helping you get insurance coverage or otherwise provide for payment for your health care. We may use or disclose your PHI to notify your family or personal representative of your location or condition. In an emergency or when you are not capable of agreeing or objecting to these disclosures, we will disclose PHI as we determine is in your best interest, but will give you the opportunity to object to future disclosures to family and friends if possible. Unless you object, we may also disclose your PHI to persons performing disaster relief activities.

(C) Certain Uses and Disclosures Do Not Require Your Authorization. The law allows us to disclose PHI without your authorization in the following circumstances:

(1) When Required by Law. We disclose PHI when we are required to do so by federal, state or local law.

(2) For Public Health Activities. For example, we disclose PHI when we report adverse reactions to a drug or medical device, or to notify a person who may have been exposed to a disease in compliance with applicable law. We may also report PHI to the local emergency medical services agency in connection with its oversight role over ambulance services. We may also use and disclose your PHI as necessary to comply with federal and state laws that govern workplace safety.

(3) For Reports About Victims of Abuse, Neglect or Domestic Violence. We will disclose your PHI in these reports only if we are required or authorized by law to do so, or if you otherwise agree.

(4) To Health Oversight Agencies. We will provide PHI as requested to government agencies who have authority to audit or investigate our operations.

(5) For Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court order or administrative order. We may also disclose your PHI in response to a subpoena or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain a court order that will protect the PHI requested.

(6) To Law Enforcement. We may release PHI as permitted by law if asked to do so by a law enforcement official, in the following circumstances: (a) in response to a court order issued by a court in the county where the records are located, grand-jury subpoena, court-ordered warrant, administrative request or similar process; (b) to identify or locate a suspect, fugitive, material witness or missing person; (c) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (d) about a death we believe may be due to criminal conduct; (e) about criminal conduct at our facility; and (f) in emergency circumstances, to report a crime, its location or victims, or the identity, description or location of the person who committed the crime.

(7) To Coroners, Medical Examiners and Funeral Directors. We may disclose PHI to facilitate the duties of these individuals.

(8) To Organ Procurement Organizations. We may disclose PHI to facilitate organ donation and transplantation.

(9) To Avert a Serious Threat to Health or Safety. We may disclose your PHI to someone who can help prevent a serious threat to your health and safety or the health and safety of another person or the public.

(10) For Specialized Government Functions. For example, we may disclose your PHI to authorized federal officials for intelligence and national security activities that are authorized by law, or so that they may provide protective services to the President or foreign heads of state or conduct special investigations authorized by law.

(11) To Workers’ Compensation or Similar Programs. We may provide your PHI to these programs in order for you to obtain benefits for work-related injuries or illness.

(12) If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official as necessary for the institution to provide you with health care, to protect your health or safety or that of others or for the safety and security of the correctional institution.

IV. Other Uses and Disclosures of Your Protected Health Information.

Other uses and disclosures of your PHI that are not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you give us written authorization for a use or disclosure of your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization we will no longer use or disclosure your PHI for the purposes specified in the written authorization, except that we are unable to take back any disclosures we have already made with your permission. In addition, we can use or disclose your PHI after you have revoked your authorization for actions we have already taken in reliance on your authorization. We are also required to retain certain records of the uses and disclosures made when the authorization was in effect.

V. Your Rights Related to Your Protected Health Information. You have the following rights:

(A) The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us to limit how we use and disclose your PHI, as long as you are not asking us to limit uses and disclosures that we are required or authorized to make to the Secretary of the Department of Health and Human Services, related to our facility’s patient directory, or the disclosures described in Section III, above. Any such request must be submitted in writing to our Privacy Officer. We are not required to agree to your request. If we do agree, we will put it in writing and will abide by the agreement except when you require emergency treatment.

(B) The Right to Choose How We Communicate With You. You have the right to ask that we send information to you at a specific address (for example, at work rather than at home) or in a specific manner (for example, by e-mail rather than by regular mail, or never by telephone). We must agree to your request as long as it would not be disruptive to our operations to do so. You must make any such request in writing, addressed to our Privacy Officer.

(C) The Right to See and Copy Your PHI. Except for limited circumstances, you may look at and copy your PHI that may be used to make decisions about your care if you ask in writing to do so. Any such request must be addressed to our Privacy Officer at 1500 Bollinger Canyon Road, San Ramon, CA 94583. In certain situations we may deny your request, but if we do, we will tell you in writing of the reasons for the denial and explain your rights with regard to having the denial reviewed. If you ask us to copy your PHI, we will charge you $1.00 for the first page and $0.15 for each additional page. Alternatively, we may provide you with a summary or explanation of your PHI, as long as you agree to that and to the cost, in advance.

(D) The Right to Correct or Update Your PHI. If you believe that the PHI we have about you is incomplete or incorrect, you may ask us to amend it. Any such request must be made in writing you must tell us why you think the amendment is appropriate. In addition, the following procedures apply:

We will not process your request if it is not in writing or does not tell us why you think the amendment is appropriate. We will inform you in writing as to whether the amendment will be made or denied. If we agree to make the amendment, we will ask you who else you would like us to notify of the amendment. We may deny your request if you ask us to amend information that:

(1) was not created by us, unless the person who created the information is no longer available to make the amendment;

(2) is not part of the PHI we keep about you;

(3) is not part of the PHI that you would be allowed to see or copy; or

(4) is determined by us to be accurate and complete.

If we deny the requested amendment, we will tell you in writing how to submit a statement of disagreement or complaint, or to request inclusion of your original amendment request in your PHI.

Any request covered by this paragraph D. must be made in writing and must be addressed to our Privacy Officer at the Administration Office at 1500 Bollinger Canyon Road, San Ramon, CA 94583.

(E) The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include certain disclosures, such as disclosures we have made for treatment, payment and health care operations purposes, those that are a byproduct of another use or disclosure permitted under our privacy policies or by law, those made under an authorization provided by you, those made directly to you or your family or friends or through our facility directory, or for disaster relief purposes. Neither will the list include disclosures we have made for national security purposes or to law enforcement personnel, or disclosures made before April 14, 2003.

Your request for a list of disclosures must be made in writing and be addressed to our Privacy Officer at the Administration Office at 1500 Bollinger Canyon Road, San Ramon, CA 94583 The list we provide will include disclosures made within the last six years (except not for those made prior to April 14, 2003) unless you specify a shorter period. The first list you request within a 12-month period will be free. You will be charged our costs for providing any additional lists within the 12-month period.

(F) The Right to Get a Paper Copy of This Notice. Even if you have agreed to receive the Notice by e-mail, you have the right to request a paper copy as well. You may obtain a paper copy of this Notice by contacting the Administration Office at:

1500 Bollinger Canyon Road, San Ramon, CA 94583 at (925) 838-6600.

VI. Complaints.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the federal Department of Health and Human Services. To file a complaint with us, put your compliant in writing and address it to our Privacy Officer at the Administration Building, 1500 Bollinger Canyon Road, San Ramon, CA 94583. We will not retaliate against you for filing a complaint. You may also contact our Privacy Officer if you have questions or comments about our privacy practices.

 

Effective Date: April 14, 2003