Privacy Pledge, effective April 14, 2003
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Our Pledge to Protect Your Privacy
Pacific Free Clinic knows that health information about you is personal, and we are committed to protecting the privacy of your information. As a patient of Pacific Free Clinic, the care and treatment you receive is recorded in a healthcare record, which includes the records of your medical and psychological care. So that we can best meet your medical needs, we must share your healthcare record with the health care providers involved in your care. We share your health information only to the extent necessary to collect payment for certain services we provide to you, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose your health information for any other purpose without your permission.
We are required by law to:
- make sure that your health information is kept private, particularly your psychological care records;
- give you this Notice of our legal duties and privacy practices with respect to health information about you; and
- follow the terms of the Notice that is currently in effect.
We have a responsibility to safeguard the privacy and integrity of your records. This Notice explains our privacy practices and your rights regarding your health information.
Who Will Follow This Notice
The following parties share Pacific Free Clinic’s commitment to protect your privacy and will comply with this Notice:
- Any health care professional authorized to enter information into your healthcare records,
- All units of Pacific Free Clinic, including Medical Services and Health Promotion Services
- All employees, volunteers, trainees, contractors and medical staff members of Pacific Free Clinic.
Your Rights Regarding Health Information About You
You* have the following rights regarding your health information:
Right to Inspect and Obtain A Copy of Your Healthcare Record: You have the right to inspect and obtain a copy of the healthcare records that Pacific Free Clinic uses to make decisions about you and your treatment, subject to certain limited exceptions. This information includes your healthcare records.
Right to Request a Correction or Add an Addendum to Your Healthcare Record:
- Correction: If you believe that health information Pacific Free Clinic has on file about you is incorrect or incomplete, you may ask us to correct the health information in your records. If your health information is accurate and complete, or if the information was not created by Pacific Free Clinic, we may deny your request; however, if we deny any part of your request, we will provide you with a written explanation of our reasons for doing so.
- Addendum: In addition, if you believe that an item or statement in the healthcare record is incorrect or incomplete, you have the right to provide Pacific Free Clinic with a written addendum to the record.
Right to an Accounting of Pacific Free Clinic Disclosures of Your Health Information: You have the right to request an “accounting of disclosures” which is a list describing how we have shared your health information with outside parties. This accounting is a list of the disclosures we made of your health information after April 14, 2003 for purposes other than treatment, payment and health care operations, as those functions are described below in the section of this Notice entitled, “How We May Use and Disclose Health Information About You”.
Right to Request Restrictions: You have the right to request restrictions on certain uses or disclosures of your health information. Requests for restrictions must be in writing; the appropriate instructions and forms are available at the registration area. We are not required to agree to your requested restriction. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or comply with the law. If we cannot accept your request, we will explain to you in writing why we cannot do so.
Right to Request Confidential Communications: You have the right to request that we communicate with you about healthcare matters in a certain manner or at a certain location. For example, you can ask that we only contact you at work, rather than at your home. You may request confidential communications by changing your contact information for communication at the Registration desk at Pacific Free Clinic. We will not ask you the reason for your request, and we will use our best efforts to accommodate all reasonable requests.
Right to a Copy of This Notice Upon Request: You have the right to a copy of this Notice. It is available in the registration area.
Contact Information: To obtain information about how to request a copy of your healthcare records, receive an accounting of disclosures of, or correct or add an addendum to your health information:
For medical records, call (408) 705-0119
How We May Use And Disclose Health Information About You
The following sections describe different ways that we use and disclose your health information. For each category of uses or disclosures we will provide examples. To respect your privacy, we will try to limit the amount of information that we use or disclose to that which is the “minimum necessary” to accomplish the purpose of the use or disclosure. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
When these uses involve your psychological care records, particularly any substance abuse treatment, we must often follow additional rules. If your permission is legally necessary under those rules, you will be asked.
For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, residents, nurses, technicians, or other medical and counseling personnel who are involved in your care at Pacific Free Clinic and elsewhere. For example, a doctor treating you for a broken leg needs to know if you have diabetes because diabetes can slow the healing process. Different units of Pacific Free Clinic also may share health information about you in order to coordinate the different services you need, such as pharmacy, lab work and x-rays.
For Health Care Operations: We may use and disclose health information about you for functions that are necessary to run Pacific Free Clinic and assure that all of our patients receive quality care. We may also share your health information with affiliated health care providers so that they may jointly perform certain business operations. For example, we may use health information to review our treatment and services and evaluate the performance of our staff in caring for you. We may combine health information about many of our patients to decide what additional services Pacific Free Clinic should offer, and what services are not needed. We may share information with doctors, residents, nurses, technicians, and other medical and counseling personnel for quality assurance and educational purposes.
Business Associates: Pacific Free Clinic contracts with outside companies that perform business services for us, such as management consultants, quality assurance reviewers, attorneys, or information technology specialists. In certain circumstances, we may need to share your health information with a business associate so it can perform a service on our behalf. Pacific Free Clinic will limit the disclosure of your information to a business associate to the amount of information that is the “minimum necessary” for the company to perform services for Pacific Free Clinic. In addition, we will have a written contract in place with the business associate requiring it to protect the privacy of your health information.
Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at Pacific Free Clinic.
Treatment Alternatives: We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care: Unless there is a specific written request from you to the contrary, we may release health information about you to a family member or friend who is involved in your care, give information to someone who helps pay for your care, and notify a family member, personal representative or another person responsible for your care about your location and general condition. In addition, we may disclose health information about you to an organization assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status and location.
Research: As an affiliate of Stanford’s academic medical center, Pacific Free Clinic occasionally conduct studies that may involve your current care or that involve reviews of your medical history. For example, a study may involve an investigational procedure to treat a condition or compare the health and recovery of patients who have received one medication with those who have received another for the same condition. We generally ask for your written authorization before using your health information or sharing it with others in order to conduct research. Under limited circumstances we may use and disclose your health information without your authorization. In most of these latter situations, we must obtain approval through an independent review process to ensure that research conducted without your authorization poses minimal risk to your privacy.
To Prevent a Serious Threat to Health or Safety: We may use and disclose certain information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. However, any such disclosure will only be to someone able to help prevent the threat, such as law enforcement, or to a potential victim. For example, we may need to disclose information to police if you have stated that you intend to harm yourself or someone else.
Additional Situations That Do Not Require Us To Obtain Your Authorization
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Activities: We may disclose health information about you for public health activities. These activities include, but are not limited to the following:
- to prevent or control disease, injury or disability;
- to report the abuse or neglect of children, elders and dependent adults;
- to report reactions to medications or problems with products;
- to notify you of the recall of products you 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 you have been the victim of abuse, neglect or domestic violence, but only when required or authorized by law; and
- to notify appropriate state registries, such as the Northern California Cancer Center or the California Emergency Medical Services Authority, when you seek treatment at Pacific Free Clinic for certain diseases or conditions.
Health Oversight Activities: We may disclose health information to a health oversight agency, such as the California Department of Health Services or the Center for Medicare and Medicaid Services, for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. 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 a 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, legally enforceable discovery request, or other lawful process by someone else involved in the dispute.
Law Enforcement: We may release health information if asked to do so by law enforcement officials in the following limited circumstances:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, the victim is unable to consent;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at Pacific Free Clinic; 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.
Coroners, Medical Examiners and Funeral Directors: We may release health information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release health information about patients of Pacific Free Clinic to funeral directors as necessary to carry out their duties with respect to the deceased.
Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
National Security and Intelligence Activities: Upon receipt of a request, we may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We will only provide this information after the Privacy Officer has verified the validity of the request and reviewed and approved our response.
Other Uses or Disclosures Required By Law: We will also disclose health information about you when required to do so by federal, state or local laws that are not specifically mentioned in this Notice.
Changes To This Notice
We reserve the right to change our privacy practices and update this Notice accordingly. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We post copies of the current Notice in the public area at Pacific Free Clinic. If the Notice is changed, we will post the new Notice in our public registration area and provide it to you upon request. The Notice contains the effective date on the first page, in the top right-hand corner.
Comments or Complaints
We welcome your comments about our Notice and our privacy practices. If you believe your privacy rights have been violated, you may file a complaint with Pacific Free Clinic or with the Secretary of the Department of Health and Human Services (200 Independence Avenue, S.W., Washington, D.C. 20201).
Please be assured that no one will retaliate or take action against you for filing a complaint.
Other Uses Of Health Information And Revocations Of Uses
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 authorization. If you provide us authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the activities covered by the authorization, except if we have already acted in reliance on your permission. We are unable to take back any disclosures we have already made with your authorization.
If You Have Any Questions About This Notice Please Contact Pacific’s Privacy Officer at 650 799-2173.
* “You” in this Notice means a Pacific patient or, if applicable, the patient’s personal representative. A personal representative is any person authorized to act on behalf of the patient with respect to his/her health care. For example, a personal representative may include the parent or guardian of a minor (unless the minor has the authority under California law to act on his/her own behalf), the guardian or conservator of an adult patient, or the person authorized to act on behalf of a deceased patient.