This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
If you have questions about this notice, you may contact the Share Our Selves Privacy Officer in either of the following ways:
• You can call 949-536-3987.
• You can e-mail compliance@shareourselves.org.
You can also view additional information about Notices of Privacy Practices at the following website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Our Pledge Regarding Protected Health Information
- We understand that information about you and your health is personal. We are committed to protecting the privacy of your protected health information.
- We create a record of the care and services you receive at Share Our Selves, and we may receive similar records from others.
- We use these records to provide you with quality care and to comply with legal requirements.
- This Notice tells you about the ways we may use and disclose information about you. It also describes your rights, and the obligations we have regarding the use and disclosure of your information.
We are required by law to do the following:
- Make sure that information that identifies you is kept private.
- Give you this Notice of our legal duties and privacy practices with respect to information about you.
- Follow the terms of the Notice we currently have in effect.
A. Who Will Follow This Notice
• This Notice describes Share Our Selves’ practices and the practices of all of the following entities:
– Any health care professional authorized to enter information into your electronic health
record
– Share Our Selves Pharmacy
– All employees, contractors, volunteers, staff, and other Share Our Selves personnel
• There may also be other state and federal laws that Share Our Selves and other health care providers will follow that provide additional protections related to:
– communicable disease
– mental health
– substance or alcohol abuse
– other health conditions
B. How Share Our Selves May Use or Disclose Your Protected Information
Following are the different ways we may lawfully use or disclose your protected health information. The examples provided in each section do not represent all the ways your protected health information may be used. They are only intended to generally describe situations when uses or disclosures may happen.
1. For Treatment
Our use:
• We may use your protected health information to provide you with comprehensive medical, dental, pharmacy, and social services.
For example:
– We may disclose protected health information about you to Share Our Selves doctors, nurses, technicians, case workers, and other Share Our Selves employees who are involved
in providing the care you need.
– We may also share your protected health information with a provider or entity outside of Share Our Selves in order to provide or coordinate services for you such as ordering outside lab work or an x-ray
2. For Payment
Our use:
• We may use and disclose your protected health information to obtain payment for the services we provide.
– We give your health insurance plan the information it requires before it will pay us.
• We may also contact a health insurance plan or a third-party payor about a treatment or service you are going to receive in the future. We would do this so we can obtain prior
approval or to determine what your insurance plan may cover
3. For Health Care Operations
Our use:
• We may use and disclose your protected health information to operate this clinic. These types of uses and disclosures are necessary to run Share Our Selves and ensure that all our patients and clients receive quality care.
For example:
– We may use medical information to review our treatment and services and to evaluate the staff caring for you.
– We may also combine information about many clinic patients together to make operational decisions, for example, to determine what additional services the clinic should
offer, or if a certain treatment is effective.
– We may also disclose information to our staff for learning and review purposes.
– We may also compare the information we have with other clinics or organizations to compare how we are doing and to make improvements in the services and care we offer.
– We may remove information that identifies you from these sets of medical information so that others may use it without learning who the specific patient is.
Use by a third party:
• We may also share your protected health information with a third-party “business associate” who is assisting us with clinic operations.
For example:
– We might share protected health information with a billing service performing administrative services
– We might share protected health information with an information technology firm assisting us with our electronic medical record maintenance. We have a written contract with each of these business associates which requires them to protect the confidentiality of your protected health information.
4. For Health-related Benefits and Alternative Services
Our use:
• We may use and disclose protected health information to tell you about health-related services, benefits, or programs that might benefit you.
• We may also disclose protected health information to tell you about or recommend possible treatment options or alternatives.
5. To Individuals Involved in Your Care
Our use:
• We may release your protected health information to a friend or family member who is involved in your care or who helps pay for your care.
Note: If you have given someone power of attorney, or if someone is your legal guardian, that person can exercise your rights, and make choices about your protected health information. We will make sure the person has the authority, and can act for you, before we take any action.
• In addition, in the event of a disaster, we may disclose information about you to an entity assisting in a disaster relief effort.
Note: California law requires that only basic information such as your name, city of residence, age, sex, and general condition be provided in response to a disaster welfare
inquiry.
6. As Required by Law
Use by another entity:
We will disclose your protected health information when required to do so by federal, state, or local law.
For example:
– In some circumstances the law may require your physician to report instances of abuse, violence, or neglect.
7. To Avert a Serious Threat to Health or Safety
Use by another entity:
• We may use or disclose your protected health information 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, or lessen the threat.
8. For Research Purposes
Use by another entity:
Share Our Selves may participate in research projects conducted by various entities.
• All research projects are reviewed and approved through a special review process to protect patient safety, welfare, and confidentiality.
• Your protected health information may be important to research efforts and the development of new knowledge. We may use and disclose protected health information for this purpose.
• Research studies may be performed using information about your treatment without requiring informed consent.
For example:
– A research study may involve comparing the health of patients
Special Situations
9. Public Health Activities
Use by another entity:
We may disclose information about you to various public health entities for public health purposes. These purposes generally include the following:
a. Preventing or controlling diseases (such as cancer and tuberculosis), injury, or disability
b. Reporting vital events such as births and deaths
c. Public health surveillance, investigations, interventions, or at the direction of a public health authority.
d. Providing it to an official of a foreign government agency acting in collaboration with a public health authority
e. Reporting child abuse or neglect
f. Reporting adverse events or reactions related to foods, drugs, or products
g. Notifying people of recalls, repairs, or replacements of products they may be using
h. Notifying a person who may have been exposed to a disease or who may be at risk of contracting or spreading a disease or condition
i. Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence, and make this disclosure as required or authorized by law.
10. Health Oversight Activities
Use by another entity:
• We may disclose protected health information to governmental, licensing, auditing, and accrediting agencies for activities authorized by federal and California law.
11. Lawsuits and Other Legal Actions
Use by another entity:
• We may disclose information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful proceeding.
12. Law Enforcement
Use by another entity:
• We may disclose your protected health information to law enforcement officials upon their request, for any of the following reasons:
– In response to a court order, subpoena, warrant, investigative demand, or other similar process
– To help identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the
victim’s agreement
– About a death we believe may be the result of criminal conduct; about criminal conduct occurring on our premises
– 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
13. Coroners, Medical Examiners, and Funeral Directors
Use by another entity:
• We may, and are often required by law, to disclose your protected health information to coroners, medical examiners, and/or funeral directors. This is done to assist these professionals with their investigation of death or to help them carry out their professional duties.
14. Organ and Tissue Donation
Use by another entity:
• We may disclose your protected health information to organizations involved in obtaining, storing, or transplanting organs and tissues.
• You may request, in writing, a restriction on how much information we share when responding to requests about the appropriateness of obtaining, storing, or transplanting
organs and tissue.
For example:
– Since HIV is usually a reason not to do these activities, you may ask us in writing to simply say it is not medically appropriate, without providing more information about the reasons why it is not appropriate.
15. Military, National Security, and Intelligence Activities
Use by another entity:
• We may disclose your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
• We may also release protected health information about you to federal officials so they may provide protection to the President, other authorized persons, or foreign heads of states. If the law so requires.
16. Inmates
Use by another entity:
• If you are an inmate of a correctional institution, or under the custody of law enforcement officials, we may release your protected health information to the correctional institution or to a law enforcement official.
• This release would be necessary for any of the following reasons:
a. For the institution to provide you with health care
b. To protect your health and safety or the safety of others
c. For the safety and security of the correctional institution.
17. Worker’s Compensation
Use by another entity:
• We may disclose your protected health information as necessary to comply with Worker’s Compensation laws.
• These programs provide benefits for work-related injuries or illnesses.
For example:
– If your care is covered by Worker’s Compensation, we will make periodic reports to your employer about your condition.
– We are also required to report cases of occupational injury or occupational illness to the employer or Worker’s Compensation insurer.
18. Outreach and Fundraising Activities
Our use:
• We will not use or disclose your protected health information in any of our outreach or
fundraising activities.
• However, we may use combined demographic data about many people for such activities.
For example:
– We might create a brochure to hand out at events that lists the number of Share Our Selves patients and provides basic demographic information about our patients in general.
– We may also send out fundraising information to individuals who have made donations in the past or who may make donations in the future, and to past patients.
If you want to exclude your personal information from being used in this way, notify the Privacy Officer at the telephone number or e-mail address listed at the top of this Notice.
19. Psychotherapy Notes
Use by another entity
• We will not use or disclose your psychotherapy notes without your express written consent, except in limited circumstances related to payment, treatment, and other health care
operations, as allowable by law. We Never Sell Your Information
20. Marketing and Sales
Our use
• We will never use your information for marketing purposes without first obtaining your express written consent.
C. Your Rights Regarding Your Protected Health Information
1. Your Right to Inspect and Copy
• With certain exceptions, you have the right to inspect and copy your protected health information.
• To access your protected health information, you must submit a request, in writing, to:
Health Information Management
Share Our Selves
20151 SW Birch St.
Suite 100
Newport Beach, CA 92660
• If you request a copy of this information we will provide it to you within 15 days, and we may charge you a reasonable fee. If there are any circumstances which prevent us from fulfilling your request within 15 days, we will notify you of the delay.
• We may deny your request under limited circumstances. If we deny your request to access your records, you have the right to appeal our decision. If we deny your request to access
your psychotherapy notes, you have the right to have them transferred to another health professional.
• If your written request clearly, conspicuously, and specifically asks us to send an electronic copy of your medical record to you or another person or entity, and we do not deny the request, we will send a copy of the electronic record as you requested and will charge you no more than what it costs us to respond to your request.
2. Your Right to Amend or Supplement
• If you feel the information that we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum.
• You have the right to seek an amendment or addendum for as long as the information is kept by Share Our Selves.
• To request an amendment or addendum, a request must be made, in writing, and submitted to:
Health Information Management
Share Our Selves
20151 SW Birch St.
Suite 100
Newport Beach, CA 92660
• In addition, you must provide a reason that supports your request.
• An addendum may not be more than 250 words per alleged incomplete or incorrect item in your record.
• We may deny your request for an amendment or an addendum regarding your protected health information or record for any of the following reasons:
– The request is not in writing.
– The health information was not created by Share Our Selves, is not part of the designated record set.
– The health information is already accurate and complete.
– The health information is not information you are permitted to review (as outlined in §164.524 of the Health Insurance Portability and Accountability Act).
• If we deny your request we will explain why, in writing, within sixty (60) days.
3. Your Right to an Accounting of Disclosures
• You have a right to receive an “accounting of disclosures.”
• The accounting is a list of the disclosures of your protected health information we have made in the last six (6) years that were for purposes other than treatment, payment, or health care operations, and certain other purposes.
• To request an accounting of disclosures, you must submit your request, in writing to:
Health Information Management
Share Our Selves
20151 SW Birch St.
Suite 100
Newport Beach, CA 92660
• Your request should also indicate in what form you want the list (for example, on paper or
electronically).
• The first 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 and you may choose to
withdraw or modify your request.
4. Your Right to Request Restrictions
• You have the right to request a restriction or limitation on the protected health 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 protected 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:
– You could ask that we not use or disclose information about a specific medication you are taking.
• To request restrictions, you must make your request in writing to:
Health Information Management
Share Our Selves
20151 SW Birch St.
Suite 100
Newport Beach, CA 92660
In your request, you must tell us:
a. what information you want to limit;
b. whether you want to limit our use, disclosure, or both; and
c. to whom you want these limits to apply, for example, disclosures to your spouse.
• In general, we are not required to agree with your request.
• If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, or we are compelled to disclose the information under the law.
• However, if you tell us not to disclose health information to your commercial health insurance plan, and you pay for the services out-of-pocket and in full at the time of service, we are required by law to comply with your request.
5. Your Right to Request Confidential Communications
• You have the right to request that you receive your protected health information in a specific way or at a specific location.
For example:
– You may ask that we send information to your work address.
• We will comply with all reasonable requests submitted in writing to:
Health Information Management
Share Our Selves
20151 SW Birch St.
Suite 100
Newport Beach, CA 92660
• The request must specify how or where you wish to receive these communications. We must comply with your request if you inform us that not doing so will put you in danger.
6. Your Right to a Paper Copy of this Notice
• You can receive a paper copy of this Notice even if you have previously received this Notice electronically.
• If you would like to have a more detailed explanation of these rights, or if you would like to exercise one or more of these rights, contact our Privacy Officer at the telephone number or e-mail address listed at the top of this Notice.
D. Breach Notification
• If, despite Share Our Selves’ efforts to keep your protected health information confidential, a breach of unsecured protected health information occurs, we will notify you as required by law.
• In some instances, our business associate may provide the notification.
• The law also requires us to report any breach of protected health information to both state and federal authorities.
E. The OCHIN Collaborative
• Share Our Selves is part of an organized health care arrangement which includes other participants in OCHIN.
• A current list of OCHIN participants is available at www.ochin.org.
• As a business associate of Share Our Selves, OCHIN supplies information technology and related services to Share Our Selves and other OCHIN participants.
• OCHIN also engages in quality assessment and improvement activities on behalf of its participants.
For example:
– OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and access clinical benefits that may be derived from the
use of electronic health record systems.
– OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals.
Use of your protected information by OCHIN or a Health Information Exchange (HIE)
• Your protected health information may be shared by Share Our Selves with other OCHIN participants or a health information exchange (HIE) only when necessary for medical treatment or for the health care operation purposes of the organized health care arrangement.
• OCHIN also engages in quality assessment and improvement activities on behalf of its participants.
For example:
– Health care operation can include, among other things, geocoding your residence location to improve the clinical benefits you receive.
• The protected health information may include past, present, and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy rules or any other applicable laws as amended from time to time.
• You have the right to change your mind and withdraw this consent, however the information may have already been provided as allowed by you. This consent will remain in effect until revoked by you in writing.
• If requested, you will be provided a list of entities to which your information has been disclosed.
• We participate in one or more health information exchanges (HIEs) and may electronically share your medical information for treatment, payment, and healthcare operations purposes with other participants in the HIEs.
• HIEs allow health care providers to efficiently access and use medical information necessary to your treatment and other lawful purposes.
• The inclusion of your medical information is voluntary and, subject to your right to opt-out of this exchange of information, we may provide your medical information in accordance with applicable law to the HIEs in which we participate.
• For more information on any HIE in which we participate, and how you can exercise your right to opt-out, please contact the Privacy Officer at the telephone number or e-mail address at the top of this Notice.
F. Changes to This Notice of Privacy Practices
• We reserve the right to change Share Our Selves’ privacy practices and this Notice at any time.
• Until a change is made, we are required by law to comply with this Notice.
• After a change is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain, regardless of when it was created or received.
• We will keep a copy of the current notice posted in our reception areas and will offer you a copy at your next appointment after changes have been made. We will also post the current notice on our website.
G. Complaints
• Complaints regarding our Notice of Privacy Practices, or how Share Our Selves handles your protected health information, should be directed to our Privacy Officer at the telephone
number or e-mail address listed at the top of this Notice.
• You will not be penalized or retaliated against for filing a complaint.
• If you are not satisfied with how Share Our Selves handles a complaint, you may take any of the following steps:
– You may submit a formal written complaint to the Office of Civil Rights at:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
– Or you may email your complaint to: OCRComplaint@hhs.gov
– To file a complaint online, visit https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf
For more information on filing a complaint with the Office of Civil Rights, visit:
https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html