THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Who Will Follow This Notice?
The entities listed below and their affiliated clinics and institutes of care (“We”) will follow the terms of this Notice and will only use or disclose your health information as is described in this Notice. We are an organized health care arrangement and for purposes of our privacy practices, are considered one single entity, the Loma Linda University Adventist Health Sciences Center Organized Health Care Arrangement ("LLUAHSC Organized Health Care Arrangement” or “LLUAHSC OHCA”). A detailed listing of the affiliated clinics and institutes of care affected by this Notice is provided on page 10 in a section titled “Entities That Are Included in the LLUAHSC Organized Health Care Arrangement”.
LOMA LINDA UNIVERSITY
LOMA LINDA UNIVERSITY HEALTH CARE
LOMA LINDA UNIVERSITY FACULTY PRACTICE PLAN
LOMA LINDA UNIVERSITY MEDICAL CENTER
LOMA LINDA UNIVERSITY CHILDREN’S HOSPITAL
LOMA LINDA UNIVERSITY EAST CAMPUS
LOMA LINDA UNIVERSITY BEHAVIORAL MEDICINE CENTER
The terms “use” and “disclosure” will be referenced frequently throughout this Notice. As you read this Notice, understand that “use” applies only to activities within our entity and “disclosure” applies to activities such as releasing, transferring, or providing access to information about you to other parties outside our entity.
I. Your Health Information
We know that health information about you is personal and we are committed to protecting the privacy of your information. As a patient, the care and treatment you receive is recorded in a health record. So that we can best meet your health care needs, we may share your record with the health care providers involved in your care for treatment and payment purposes.
For any other reason besides treatment and payment, we can not share your information without your written permission unless the law specifically permits or requires that we do so. For example, in most circumstances, laws pertaining to mental health and substance abuse related services require that we obtain your written permission.
II. Your Health Information Rights
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the following rights regarding health information we maintain about you:
Right of Access to Inspect and Copy
• You have the right to inspect and obtain a copy of information in your health and billing record with the exception of items limited and/or prohibited by law. You must submit your request in writing to the department/address listed in the “Contact Information” section of this Notice. If you request a copy of your health information, a fee for the costs of copying may apply.
In limited circumstances, we may deny your request to access your health information. If you are denied access to health information you may request in some instances that the denial be reviewed. In this case, we will conduct an independent review and comply with the outcome of the review.
• Mental Health and Substance Abuse Records:
A provider can lawfully deny access to the patient of the patient’s mental health records/substance abuse records when the provider determines that there is a substantial risk of harm to the patient in seeing or receiving a copy.
A provider may choose to furnish a summary report in lieu of permitting inspection or providing copies of the record.
Right to Request an Amendment to Your Record
• You have the right to request an amendment to your record if you feel that health information we have about you is incorrect or incomplete. You have the right to request an amendment for as long as the information is kept by or for an entity within the LLUAHSC OHCA. To request an amendment, you must submit your request in writing to the department/address listed in the “Contact Information” section on page 9 of this Notice. 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:
o Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
o Is not part of the health information kept by or for us;
o Is not part of the information which you would be permitted to inspect and copy; or
o Is accurate and complete
Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your health record, then we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.
Right to an Accounting of Disclosures
• You have the right to request a list (called an Accounting of Disclosures) of certain disclosures that we made about you. All disclosures that are required to be listed by law will appear on the Accounting of Disclosures list. The items that typically would be listed on an Accounting of Disclosures list are indicated in the section titled “How We May Use and Disclose Health Information About You”. To request an Accounting of Disclosures, you must submit your request to the department/address listed in the “Contact Information” section on page 9. The first request for an accounting in any 12 month period is provided to you free of charge. Any subsequent requests within that 12 month period may be subject to reasonable fees allowed by law.
Right to Request Restrictions
• You have the right to request a restriction on certain uses and disclosures of your information for treatment, payment or health care operations. For example, you might request that we not share information with your insurance company about a procedure that you had. You must submit your request for this type of restriction in writing. However, we are not required to agree to your request.
• You have the right to request a limit on the health 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, while a patient, you can request we not discuss your course of treatment with a particular family member in attendance. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or as is otherwise required by law. You can speak directly with your health care provider concerning your request for these types of restrictions. Your health care provider may require that you submit your request in writing.
• You have the right to request a restriction on the use and disclosure of your health information for the facility directory. When you are an inpatient in our facility, we may provide your location in the facility and your general condition to someone who calls and asks for you by name. If you tell us your religious affiliation, we may provide your name, location in the facility, general condition and religious affiliation to members of the clergy. Unless you notify us that you object we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. You can request a restriction on the use and disclosure of your health information for the facility directory by “opting out” or requesting that we do not include any or all of your information in the facility directory. To “opt out” of the facility directory, you must make your request in writing through the Admitting or Registration desk.
Right to Confidential Communications
• You have the right to request communications of your health information by alternative means or at alternative locations. We will accommodate reasonable requests. You must submit your request for confidential communications directly to your health care provider.
Right to Notice
• You have the right to adequate notice of how we use and disclose your health information. The Notice (or Notice of Privacy Practices) must also advise you of your rights and our legal duties with respect to your health information. You have the right to receive a paper copy of the Notice upon request. A copy of the Notice currently in effect will be available through your health care provider.
III. How We May Use and Disclose Health Information About You
We can only disclose information in your record 1) with your permission or 2) if federal, state or local law tells us that we can or must disclose information in your record. We can or must disclose information in your record for the purposes listed in this section. When a federal, state or local law tells us that we can or must disclose information in your record, in certain cases, we will list these disclosures in a report if requested. Page 3, under the section titled “Right to an Accounting of Disclosures” explains how you can request a list of the people who received your information. The disclosures described below that will typically be listed on an Accounting of Disclosures are noted with the statement “Included in an Accounting of Disclosures”.
1) We May Use or Disclose Your Health Information for Treatment.
For example: We may use or disclose health information about you to doctors, nurses,
technicians, students, or other hospital personnel who are involved in taking care of you. Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, then physician will know how you are responding to treatment. We may also provide your treating physician or a subsequent health care provider with copies of
various reports that should assist him or her in treating you.
2) We May Use or Disclose Your Health Information for Payment.
For example: We may use or disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a surgical procedure you had so your health plan will pay us or reimburse you for the surgery. We may also inform your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
3) We May Use or Disclose Your Health Information for Health Care Operations.
For example: Members of the medical and clinical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also use or disclose information to doctors, nurses, technicians, students, and other hospital personnel for review and learning purposes and as necessary to conduct our business operations, to administer the policies and processes of our health staff and to comply with the laws
that govern health care. Other examples of how we may use or disclose your health information for health care operations include using or disclosing information for compliance and audit activities, customer service initiatives and the coordination or provision of spiritual care services.
4) We May Use or Disclose Your Health Information for Purposes Other Than Treatment, Payment and Health Care Operations
Unless you notify us that you object we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you, specifically, by name. See page 3 under “Right to Request Restrictions” for information on what to do if you object to your information being in the facility directory.
We may use or disclose information regarding your location and general condition to notify or assist in notifying a family member, personal representative, or another person responsible for your care. See page 3 under “Right to Request Restrictions” for information on what to do if you object to the notification of certain family members.
Communication With Family:
Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. See “Right to Request Restrictions” for information on what to do if you object to our communication with family members involved in your care.
Disaster Relief Purposes
In the event of a disaster, we may use information or disclose information to an authorized private or public entity to the extent that it is necessary to respond to the emergency situation.
We may use or disclose information to researchers when their research has been approved by an Institutional Review Board (IRB) or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also use or disclose information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the facility. Your physician or other caregiver may discuss the possibility of enrolling you in a clinical trial. Disclosures made outside our institution for an IRB/Privacy Board approved research activity where your individual permission is not given, are Included in an
Accounting of Disclosures.
Consistent with applicable law, we may use or disclose health information to funeral directors to carry out their duties. Included in an Accounting of Disclosures
Organ and Tissue Procurement Organizations:
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs and/or tissues for the purpose of tissue donation and transplant. Included in an Accounting of
We may use or disclose health information to contact you as a reminder that you have an appointment for treatment or health care.
We may use or disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Products and Services:
We may use and disclose health information to tell you about our health-related products or services that may be of interest to you.
We may contact you as part of a fund-raising effort.
Medical Staff Administration:
The Medical Staff is responsible for insuring appropriate conduct of physicians and other licensed health professionals in the provision of patient care and safety within our facilities. It is sometimes necessary for the Medical Staff administrators and committees to conduct an internal review of patient records to insure quality care by the professionals privileged to practice in our facilities.
Food and Drug Administration (FDA):
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. Included in an Accounting of Disclosures
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Included in an Accounting of Disclosures
As required by law, we may disclose your health information to public health or legal authorities for activities that include the following:
• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report the abuse or neglect of children, elders and dependent adults;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Disclosures made for public health activities are Included in an Accounting of Disclosures.
Health Oversight Activities:
We may disclose health information to a health oversight agency for activities authorized by law. Health oversight agencies include the Department of Health Services (DHS) and the Department of Health and Human Services (HHS). Oversight activities include, for example, audits, investigations, inspections and licensure. Included in an Accounting of Disclosures
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Included in an Accounting of Disclosures
Lawsuits and Disputes:
If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request by that person, (e.g., notice to consumer), which would give you an opportunity to obtain an order protecting the information requested. Included in an Accounting of Disclosures
As Required by Law:
We will disclose health information about you when required to do so by federal, state or local law. Included in an Accounting of Disclosures
To Avert a Serious Threat to Health or Safety:
We may use and disclose health 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. Included in an Accounting of Disclosures
Other Uses of Health Information
There are some services provided in our entity through contracts with business associates. An example is a transcription service we may use for transcribing physician dictation of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Other uses and disclosures
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. Disclosure made with your written permission will not be included on the Accounting of Disclosures as you will already have record of these. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your health information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. 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.
IV. Our Responsibilities
This LLUAHSC OHCA is required to:
• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
V. Other Important Information
Changes to this Notice
We reserve the right to change the terms of this notice and to make the new provisions effective for health information we maintain. We will post a copy of the current notice at each affiliated site and on our website. The notice will contain on the first page, in the top right-hand corner, the effective date.
For More Information or to Report a Problem
If you believe your privacy rights have been violated, you may file a complaint. To file a
complaint, contact the Patient Relations representative listed in the Contact Information section on page 9. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. Our Patient Relations representative can provide you with the appropriate address upon request.
Privacy Complaint Telephone Line 909-558-8282
Entities That Are Included in the LLUAHSC Organized Health Care Arrangement
Loma Linda University Medical Center (to include but not limited to)
Loma Linda University Medical Center – East Campus
Community Medical Center
Outpatient Rehabilitation Center
Diabetes Treatment Center
LLU Kidney Center
Home Health Care (includes Mountain View Pharmacy, Family Care Services, Loma Linda Medical Supplies and
Respiratory Home Care)
International Heart Institute
LLU Rehabilitation Institute
Proton Treatment Center
Loma Linda University Children’s Hospital
Loma Linda University Behavioral Medicine Center
Loma Linda University Health Care
Loma Linda University Faculty Practice Plan
Faculty Physicians and Surgeons of Loma Linda University School of Medicine:
Faculty Medical Group of Loma Linda University School of Medicine:
Loma Linda University Anesthesiology Medical Group, Inc.
Loma Linda University Cardiology Medical Group, Inc.
Loma Linda University Family Medical Group, Inc.
Loma Linda University Neurology Associates Medical Group, Inc.
Loma Linda University Pathology Medical Group, Inc.
Loma Linda University Physicians Medical Group, Inc.
Loma Linda University Preventive Medicine Medical Group, Inc.
Loma Linda University Radiation Medicine
Loma Linda University Radiology Medical Group, Inc.
Loma Linda University Surgery Medical Group, Inc.
Loma Linda University Urology Medical Group, Inc.
Loma Linda University (to include but not limited to)
Center for Health Promotion (CHP)
Marriage & Family Therapy
Department of Psychology
School of Dentistry
Allied Health Professions