Effective Date: 04/14/03
Last Updated: 09/10/13
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED OR DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact:
Santa Clara Valley Health & Hospital System
ATTN: Ethics and Compliance Officer
Ethics and Compliance Office
2325 Enborg Lane, Suite 290
San Jose, CA 95128
Phone: (408) 885-3794
WHO WILL FOLLOW THIS NOTICE
The Santa Clara Valley Health and Hospital System (SCVHHS) is a comprehensive safety-net health care system owned and operated by the County of Santa Clara (“County”). The SCVHHS is comprised of multiple County Departments, including Santa Clara Valley Medical Center and Clinics, the Mental Health Department, the Department of Alcohol and Drug Services, the Public Health Department, Custody Health Services, and Valley Health Plan (collectively “SCVHHS Departments”) all of which are “Covered Entities” under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (“HIPAA”). The SCVHHS Departments share patient health information with each other for the purposes of providing integrated care and coordinating mutual referrals and services for patients of SCVHHS Departments, for administrative oversight, billing and compliance related activities, for analysis and evaluation of services provided by SCVHHS Departments, and for entering data into and maintaining an integrated SCVHHS electronic health record. If you receive care from any of the SCVHHS Departments, your medical, mental health, drug and alcohol treatment and other information may be shared among the SCVHHS Departments.
In addition, our network of providers includes Community Clinics that have agreements with SCVHHS to provide referrals and other health related services to SCVHHS patients and County residents. We may share information with these Community Clinics regarding your care.
This Notice describes our hospital’s practices and that of:
Any health care professional authorized to enter information into your medical chart.
All departments and units of Santa Clara Valley Medical Center and Clinics, the Mental Health Department, the Department of Alcohol and Drug Services, the Public Health Department, Custody Health Services, and Valley Health Plan.
Any member of a volunteer group we allow to help you while you are being seen at the Ambulatory and Community Health Services clinics and Santa Clara Valley Medical Center.
All SCVHHS workforce members.
All of these individuals, entities, sites and locations follow the terms of this Notice. In addition, these individuals, entities, sites and locations may share medical information with each other for purposes described in this Notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
All of the SCVHHS Departments know that medical, mental health and drug and alcohol treatment information about you and your health is private and confidential. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Hospital, Clinics and SCVHHS locations. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice will tell you about the ways in which we may access, use and share your protected health information (“PHI”). It also describes your rights and certain actions we must take when using or sharing your PHI with other people or organizations. We are required by law to:
Make sure that PHI linked to you is kept private and confidential (with some exceptions as listed below);
Give you this Notice about our responsibilities and privacy practices about your PHI; and
Follow the terms of the Notice that is currently in effect.
Any use and disclosure other than explained in this Notice can only be made with your written authorization. You may revoke your authorization at any time. However, if your PHI has already been used or shared prior to receiving a revoked authorization, we cannot prevent that disclosure.
SPECIAL CATEGORIES OF INFORMATION
In some circumstances, your health information may be subject to restrictions that may limit or preclude some accesses, uses or disclosures described in this Notice. There are special restrictions on the access, use or disclosure of certain categories of information. For example, tests for HIV or treatment, for mental health conditions, or alcohol and drug abuse or emancipated minors constitute special categories of information. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program.
What is “Protected Health Information”
Protected health information or “PHI” (also referred to as “individually identifiable health information”): Any individually identifiable information, in electronic or physical form, regarding a patient’s medical history, mental or physical condition or treatment that includes or contains any element of personal identifying information sufficient to allow identification of the individual such as the patient’s name, address, e-mail address, telephone number, Social Security number, or other information that, alone or in combination with other publicly available information, reveals the individual’s identity.
HOW WE MAY USE AND SHARE PROTECTED HEALTH INFORMATION
The following sections describe different ways that we access, use and share (disclose) your PHI. To respect your privacy, we will limit the amount of information that we access, use or disclose to that which is “minimum necessary” to accomplish the purpose of the access, use or disclosure. The law limits how we can access, use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, certain types of care provided to minors, and mental illness. Not every access, use or disclosure in a category will be listed in this Notice. However, all of the ways we are permitted to access, use and disclose information will fall within one of the following categories.
Disclosure at Your Request
If you request your PHI, we may disclose information to you with limited exceptions. Some types of disclosures require a written authorization.
We may access, use and disclose your PHI to provide you with treatment or services. For example, we may disclose medical information about you to bill and receive payment for the treatment and services you receive. We may disclose medical information to doctors, nurses, technicians, health care students, medical students, or other caregivers involved in your healthcare. We may share your medical record with your doctor. We may share your PHI with a lab outside of SCVHHS that performs tests requested by your doctor. We may also share your PHI with nursing homes or other community healthcare agencies to arrange for on-going treatment after you leave the hospital. Different departments of SCVHHS may share medical information in order to coordinate services you need, such as pharmacy, lab work and x-rays. For mental health, we may share your information with professional persons who have medical or psychological responsibility for your care. For drug and alcohol treatment purposes, we may share your information to assist in your care with providers who are part of SCVHHS network, who are part of your drug and alcohol program or the Drug and Alcohol Department System of Care, or to medical personnel in a medical emergency.
We may access, use and disclose medical information about you, so that the treatment and services you receive may be billed 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 surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery. We may also tell 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. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside SCVHHS who are involved in your care, to assist them in obtaining payment for services they provide to you.
For Health Care Operations
We may access, use and share PHI for health care operations. These uses and disclosures are necessary to improve the quality of care, training and educational programs within SCVHHS, or medical staff activities. We may access, use and share your PHI to comply with laws and regulations, for contractual obligations, payer eligibility, claims submission, business planning, marketing, and to operate SCVHHS. For example, we may access, use and disclose PHI to review our treatments and services, and to evaluate our staff performance in caring for you. We may combine PHI we have with that from other health care systems or business associates to compare how we are doing, and to see where we can improve the care and services we offer.
Business Associates and Qualified Service Organizations
There are some services provided in our organization through contracts with business associates and for drug and alcohol program, Qualified Service Organizations. Business Associates and Qualified Service Organizations provide services on behalf of SCVHHS Departments that involve the use or disclosure of patient information. Examples include physician services, certain laboratory tests, billing, analysis, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associates and qualified service organizations, so that they can perform the job we have asked them to do. To protect your health information, however, business associates and qualified service organizations are required by federal law to appropriately safeguard your information. In addition, the SCVHHS Departments are business associates and qualified service organizations of each other for purposes of providing integrated care and coordinating mutual referrals and services for patients of SCVHHS Departments, for administrative oversight, billing and compliance related activities, for analysis and evaluation of services provided by SCVHHS Departments, and for entering data into and maintaining an integrated SCVHHS electronic health record.
We will access, use and share PHI to schedule an appointment, or to remind you that you have an appointment for treatment.
We will access, use and share PHI to tell you about possible treatment options that may interest you.
We may use certain information (name, address, telephone number, e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money for the hospital and you will have the right to opt out of receiving such communications with each solicitation. For the same purpose, we may provide your name to the VMC Foundation. The money raised will be used to expand and improve the services and programs we provide the community. You are free to opt out of fundraising solicitation, and your decision will have no impact on your treatment or payment for services.
1. Phone VMC Foundation at 408-885-2485;
2. Email: firstname.lastname@example.org
3. Direct mail solicitation includes a reply form with “do not solicit” box and mail to return address.
Our hospital and other facilities access and use PHI to maintain directories of people staying in our facilities, including name, location, general condition (e.g., critical, stable), and religious affiliation. This directory of information, except for your religious affiliation, may also be released to people who ask for you by name. You can make a specific written request to prevent your PHI from being disclosed in this manner. 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 information is released so your family, friends and clergy can visit you in the hospital and generally know how you are doing. If you are a patient receiving mental health services in our inpatient or outpatient mental health facilities, or enrolled in a drug and alcohol treatment program, we will not release your name or any information disclosing whether you are a patient unless you have specifically authorized us to do so.
Individuals involved in your care or payment for your care
We may share your PHI with a family member, friend, personal representative, or anyone else you want to be involved in your care We may share your PHI with anyone who helps pay for your care. Unless you tell us not to do so in writing, we may also tell your family or friends about your condition and that you are in SCVMC. In addition, we may share your PHI with an organization involved in disaster relief so that your family can learn about your condition, status and location. For mental health and drug and alcohol treatment records, we are only permitted to share your PHI with your treating physician and individuals that you designate. We cannot share your mental health and drug and alcohol treatment records to your family, friend or personal representative without an authorization, with the exception of a parent or guardian (with limited exceptions) or a Conservator.
We may access, use and share your PHI for research purposes. All research projects are evaluated under a special review and approval process. We review a research project’s access and use of PHI, and try to balance research needs with patients’ need for privacy. Alternatively, we may share your PHI with scientists preparing to conduct a research project to help them find patients with specific medical needs. In these cases, your PHI will not leave our facility. Often, our researchers contact patients about their interest in participating in certain research studies. Before you can be enrolled in a study, you must be given information about the study, be allowed to ask questions, and agree to participate by signing an informed consent form. We may perform other studies using your PHI without requiring your consent. These studies will not affect your treatment or welfare, and your PHI will continue to be protected. For example, a study may involve a chart review to compare the outcomes of patients who received different types of treatments.
Public Health Epidemiology – Population Study
We may access use and share you PHI for the purpose of studying trends in health conditions, health status and to better understand health disparities. In this case your PHI is aggregated with other individuals and the names are removed for the purpose of representing the data. We may examine issues such as income, age, gender and ethnicity as underlying factors affecting the health of populations. Population trend data may be shared with internal SCVJHHS Department and with external partners, academic institutions and may become part of larger reports on the Health Status of populations residing in Santa Clara County. At no time will the names of individuals or other personal identifying information be used, without the express consent of those individuals.
As Required By Law
We will access, use and share your PHI when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety
Unless prohibited by law, we may access, use and share your PHI when necessary to prevent or lessen a serious threat to your health and safety, or to that of others. We will only share your PHI with a responsible person who is able to help prevent the threat.
Marketing and Sale of PHI
We may not use or disclose your PHI for marketing purposes without your written authorization. We may not sell your PHI without your written authorization.
We may not use or disclose psychotherapy notes without your written authorization unless otherwise permitted or required by law.
Organ and Tissue Donation
In some circumstances we may share your PHI with organizations that handle organ procurement or organ, eye or tissue transplantation or with an organ donation bank, as necessary to help with organ or tissue donation and transplantation.
Military Service and Veterans
If you are a current or retired member of the Armed Forces, we will share your PHI if it is required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authorities as authorized or required by law.
With some exceptions for mental health and drug and alcohol treatment information, we may share your PHI as permitted by law for workers’ compensation or similar programs when necessary to provide you with treatment, services or benefits for work-related injuries or illness.
Public Health Risks
We may access, use and share your PHI for public health purposes. In general, these activities include, but are not limited to the following:
to prevent or control disease (such as cancer or tuberculosis), 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 healthcare products;
to notify patients of recalls, repairs, or replacement of products they may be using;
to notify a person who may have been exposed to a disease or may be at risk for getting 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 share your PHI only if you agree or when it is required or authorized by law.
to notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.
Health Oversight Activities
We may access, use and share your PHI with a healthcare oversight agency as authorized or required by law. These oversight activities include, for example: audits, investigations, inspections, and accreditation and licensure surveys. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes
If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical 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 (which may include written notice to you) or to obtain an order protecting the information requested. We will only disclose mental health and drug and alcohol treatment records in response to a subpoena when we receive a court order or authorization from the patient.
We may access, use and disclose PHI if asked to do so by a law enforcement official:
in compliance with a court order, subpoena, warrant, summons, grand jury subpoena or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a victim or a crime, if, under certain limited circumstances, we are unable to obtain the permission directly from the victim of a crime; about a death we believe may be the result of criminal conduct; about criminal conduct in any of our facilities; 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.
Mental Health and Department of Alcohol and Drug Services records require additional legal protections and cannot be released without a court order or an authorization by the patient or the patient’s representative, except in certain limited circumstances as allowed by law.
Coroners, Medical Examiners and Funeral Directors
We may access, use and share PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release your PHI to funeral directors when necessary for them to carry out their duties. We will only disclose mental health and drug and alcohol treatment records to the Coroner or medical examiner with a court order or an authorization from the patient’s next of kin.
National Security and Intelligence Activities
We may access, use and share your PHI to federal officials for intelligence, counterintelligence, and other national security activities as authorized or required by law.
We may use and share your PHI to authorized federal officials so they can protect the President, the President's family, other designated persons or foreign heads of state, or conduct special investigations.
If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may access, use and share your PHI with the correctional institution or law enforcement officials. Disclosure is necessary: (1) to provide the healthcare services you need; (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.
MULTIDISCIPLINARY PERSONNEL TEAMS
We may disclose PHI to a multidisciplinary personnel team relevant to the prevention,
identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.
We will disclose PHI as required by law to make a mandatory report for abuse or neglect, or any other reporting obligations.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding your PHI that we maintain in our facilities.
Right to Notice of Breach or Unauthorized Access
You have the right to be notified if there is an unauthorized access to your PHI or a breach of unsecured PHI involving your information. We are required to notify you and provide you with information on how to protect your personal information.
Right to Inspect and Copy
Except for certain information related to treatment of mental illness, or information gathered in a civil, criminal or administrative action or proceeding, or some PHI subject to the Clinical Laboratory Improvements Amendments of 1988, you have the right to ask to inspect and copy your PHI. To inspect and copy your PHI, you must send a specific, detailed request in writing to the Release of Information Unit whose address is provided at the end of this Notice.
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.
If we deny a request to inspect and copy, you may ask for a review of why we denied the request. Reviews will not be accepted if:
1) you are not entitled to the records according to the paragraph above;
2) you are an inmate and the copies would jeopardize your health safety, security, custody, or rehabilitation or that of others;
3) if the PHI is obtained as part of a research study and your right to access your PHI is suspended during the research;
4) if the PHI is controlled by the Privacy Act and access is not permitted by law; or
5) if the PHI was obtained from someone other than a healthcare provider under a promise of confidentiality and access to the PHI would reveal who that person is.
The SCVHHS Departments will choose a different licensed provider to review the reason for denial. The person who reviews your denial will not be the person who denied your initial request.
Right to Amend
If you feel that the medical information we have about you is incorrect and incomplete,
you may ask us to amend the PHI in your record. You have the right to request an amendment for as long as we keep your PHI. A request for amendment must be made in writing and must provide a reason that supports the request.
Your request for an amendment can be denied if it is not in writing or does not include a reason to support your request. We may deny your request if you ask us to change information that:
was not created by us;
is not part of the information kept by or for us;
is not part of the information which you are permitted by law to inspect and copy; or
is accurate and complete.
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.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of PHI about you other than our own for treatment, payment and health care operations (as those functions are described above), and with other exceptions pursuant to the law.
Your request must state a time period, which cannot be more than six years, and cannot include dates before April 14, 2003. Your request should describe the type of list you would like (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you 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 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 medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not access, use or share information about a surgery that you had done at SCVMC, or about a treatment you received at one of our other facilities. 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 emergency treatment to you.
You have the right to request a restriction or limitation on certain PHI provided to your health plan if you have paid out of pocket in full for the care you received from our facility.
To request restrictions 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 ask that we communicate with you about your PHI in a certain way or at a certain location. For example, you can ask that we contact you only at work or by U.S. mail. To request confidential communications, you must write to the Release of Information Unit at the address indicated in this Notice. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. You must tell us how or where you want to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice if you ask us at the address provided at the end of this Notice. You may obtain an electronic copy of this Notice at our website: www.sccgov.org, then select “Health and Human Care” and find “HIPAA Notice of Privacy Practices.”
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 the PHI we already have about you, as well as any other information we receive in the future. We will post a copy of the current Notice in our facilities. The effective date of the Notice will be displayed on the first page. The current notice will be available at www.scvmed.org.
We welcome the opportunity to respond to your questions and concerns and to resolve any complaints you may have about the access, use or disclosure of your PHI. If you believe your privacy rights have been violated, you may file a complaint with us, or with the Secretary of the Department of Health and Human Services. To file a complaint with us, you must contact:
Santa Clara Valley Health & Hospital System
Attn: Ethics and Compliance Officer
2325 Enborg Lane, Suite 290
San Jose, CA 95128
Phone: (408) 885-3794
You will not be penalized for filing a complaint.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of PHI not covered by this Notice, or by the laws that apply to us, will be made only with your written permission. If you allow us to access, use or share your PHI, you may cancel that permission, in writing, at any time. If you cancel your permission, we will stop any further access, use or disclosure of your PHI for the purposes covered by your written permission. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required by law to keep records of the services or treatment we provided to you.
CONTACT INFORMATION FOR RIGHTS INVOLVING PHI
Please contact the Release of Information Unit for 1) Requests to inspect or copies of medical record; 2) requests to amend your medical record; 3) request for an accounting of disclosures; 4) requests to restrict the release of information.
Santa Clara Valley Medical Center
Attn: Release of Information Unit Medical Record Services
751 South Bascom Avenue
San Jose, CA 95128
Right to Review
Please contact the Privacy Office of the SCVHHS Department where you receive your services at the following addresses for 1) Request for a review of a denial of your request for your PHI; 2) requests for a paper copy of this Notice; 3) requests for confidential communications.
Santa Clara Valley Medical Center
Attn: Privacy Coordinator Medical Record Services
751 S. Bascom Avenue
San Jose, CA 95128
Privacy Officer, Drug and Alcohol Department
976 Lenzen Avenue
San Jose, CA 95126
Privacy Officer, Department of Mental Health
Mental Health Department Administration
828 S. Bascom Avenue
San Jose. CA 95128
Privacy Officer, Custody Health Services
Custody Bureau Administration
180 W. Hedding St.
San Jose, Ca. 95110
Privacy Officer, Public Health Department
976 Lenzen Avenue
San Jose, CA 95126