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This document contains notification as required under the final privacy
rules issued by the Department of Health and Human Services, Washington, DC,
pursuant to the Health Insurance Portability and Accountability Act of 1996
(HIPAA) and modified to reflect California privacy laws.
THIS NOTICE
DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
If you have any questions about this Notice, please contact our Privacy
Officer at (408) 846-2100.
WHO WILL FOLLOW THIS NOTICE
This Notice describes the information privacy practices of Rebekah
Children's Services (RCS) and its affiliated staff, sites and locations.
All RCS entities, sites and locations may share information with each other
for treatment, payment or health care operations purposes within the
described limits.
OUR PLEDGE REGARDING INFORMATION
We understand that information we maintain about you is personal. We are
committed to protecting information about you. RCS creates a record of the
care and services rendered to all its clients. We need this record to
provide you with quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated by, or
available to, RCS personnel.
This Notice will tell you about the ways in which we may use and disclose
information about you. We also describe your rights and certain obligations
we have regarding the use and disclosure of information.
Under Federal and State law, RCS is required to:
- Make sure that information that identifies you is kept private, that is,
handled as "protected health information."
- Give you this Notice of our legal duties and privacy practices with
respect to information about you.
- Follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose information.
For each category of use or disclosure, we will explain what we mean. 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. In
general, it is the practice of RCS to obtain the parent or legal guardian's
signature on consent and authorization forms specific to the services RCS
will provide, and the information RCS will obtain from, or share with,
others.
For Treatment:
- We may use information about you to provide you with treatment or
services.
- We may disclose information about you to doctors, nurses, clinicians,
facilitators, counselors, specialists, interns or other agency personnel who
are involved in providing care for you at RCS.
- We also may disclose information about you to people outside of RCS or its
affiliates who may be involved in your treatment after you leave RCS, such
as family members, social workers, school employees or others involved in
providing services to you.
For Payment:
- We may use and disclose information about you so that the treatment and
services you receive at RCS may be billed to, and payment may be collected
from you, an insurance company or a third party.
- 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.
For Health Care Operations:
- We may use and disclose information about you for RCS operations. These
uses and disclosures are necessary to run RCS and make sure that all of our
children and families receive appropriate care.
- We may also combine information about many agency clients to decide what
additional services RCS should offer, what services are not needed, and
whether certain services are effective.
- We may also disclose information to doctors, nurses, clinicians, interns,
counselors, specialists and other agency personnel for review and learning
purposes.
- We may provide information to representatives of organizations with
oversight responsibility for compliance, licensure, quality of care and
funding purposes.
- We may also combine the information we have with information from other
agencies to compare how we are doing and see where we can make improvements
in the care and services we offer.
Appointment Reminders:
We may use and disclose information to contact you as a reminder that you
have an appointment for treatment or services at RCS.
Treatment Alternatives:
We may use and disclose 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 information to tell you about our health-related
products or services that may be of interest to you.
Fundraising Activities:
We may use information about you to contact you in an effort to raise money
for RCS and its operations. We may disclose information to a foundation
related to RCS, so that the foundation may contact you in raising money for
RCS. We only would release contact information, such as your name, address
and phone number and the dates you received treatment or services at RCS.
If you do not want RCS to contact you for fundraising efforts, you may
notify the Privacy Officer.
Individuals Involved in Your Care or Payment for Your Care:
We may release information about you to a friend, family member, or other
individual who is involved in your health care. We may also give
information to someone who helps pay for your care. In addition, we may
disclose information about you to an entity assisting in a disaster relief
effort so that your family can be notified about your condition, status and
location.
Research:
Under certain circumstances, we may use and disclose information about you
for research purposes. All research projects, however, are subject to a
special approval process. This process evaluates a proposed research
project and its use of information, trying to balance the research needs
with clients' need for privacy of their information. You will always be
asked for your specific permission for a researcher to access information
that reveals who you are.
Other Business Associations:
At times, RCS hires certain individuals or companies to perform temporary
functions, such as clerical tasks if a permanent staff member is out on
medical leave. RCS has a contract with each individual or company that
insures that the privacy of children and families is protected.
As Required By Law:
We will disclose information about you when required to do so by federal,
state or local law.
To Avert a Serious Threat to Health or Safety:
We may use and disclose 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.
SPECIAL SITUATIONS
Military and Veterans:
If you or your child is now, or in the future, a member of the armed forces,
we may release information about you as required by military command
authorities if it relates to a "military mission." We may also release
information about foreign military personnel to the appropriate foreign
military authority.
Health Oversight Activities:
We may disclose information to a health oversight agency for activities
authorized by law, for example Community Care Licensing, or Santa Clara
County Mental Health. These oversight activities include, for example,
audits, investigations, inspections, and licensure.
Public Health Risks:
We may disclose information about you for public health activities. These
activities generally 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.
Lawsuits and Disputes:
If you are involved in a lawsuit or a dispute, we may disclose information
about you in response to a court or administrative order. In the case of an
administrative order, legal counsel will be consulted. We may also disclose
information about you in response to a subpoena, discovery request, or other
lawful process by someone else involved in the dispute.
Law Enforcement:
We may release information if asked to do so by a law enforcement official:
- About the victim of a crime if, under certain limited circumstances, we
are unable to obtain the person's agreement;
- In response to a court order, subpoena, warrant, summons or similar
process;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at RCS.
Workers' Compensation:
We may release information about you for workers' compensation or similar
programs. These programs provide benefits for work-related injuries or
illness.
Organ and Tissue Donation:
We may release information to organizations that handle organ procurement or
organ, eye or tissue transplantation, or to an organ donation bank, as
necessary to facilitate organ or tissue donation and transplantation.
Coroners, Health Examiners and Funeral Directors:
We may release information to a coroner or health examiner. This may be
necessary, for example, to identify a deceased person or determine the cause
of death.
National Security and Intelligence Activities:
We may release information about you to authorized federal officials for
intelligence, counterintelligence, and other national security activities
authorized by law.
Protective Services for the President and Others:
We may disclose information about you to authorized federal officials so
they may provide protection to the President, other authorized persons, or
foreign heads of state, or conduct special investigations.
Inmates:
If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release information about you to the
correctional institution or law enforcement official. This release would be
necessary (1) For the institution to provide you with health care; (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.
YOUR RIGHTS REGARDING INFORMATION ABOUT YOU
You have the following rights regarding information we maintain about you:
Right to Inspect and Receive a Copy:
You have the right to inspect and receive copies of information that may be
used to make decisions about your care. Usually, this includes health and
billing records, but may not include some mental health information. To
inspect and request a copy of information that may be used to make decisions
about you, you must submit your request in writing to the Privacy Officer.
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. We may
deny your request to inspect and obtain a copy in certain very limited
circumstances. We may offer a summary of your treatment rather than the
complete record. If you are denied access to information, you may request
that the denial be reviewed. Another licensed health care professional
chosen by RCS will review your request and the denial. The person
conducting the review will not be the person who denied your request. We
will comply with the outcome of the review. RCS maintains records for a
period of time consistent with federal and state legislated retention
periods.
Right to Amend:
If you feel that information we have about you is incorrect or incomplete,
you may ask us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for RCS. To request
an amendment, your request must be made in writing and submitted to the
Privacy Officer. 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 it does not include a reason to support the request. In addition, we may
deny your request to amend information that (1) was not created by us; (2)
is not part of the information kept by or for RCS; or is not part of the
information which you would be permitted to inspect and copy; or (3) is
accurate and complete. Even if we deny your request for amendment, you have
the right to submit a written addendum, within reasonable limits, 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, 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 an "accounting of disclosures." This is a
list of the disclosures we made of information about you other than our own
uses for treatment, payment and health care operations, as those functions
are described above, and with other expectations pursuant to the law. To
request this list, or accounting of disclosures, you must submit your
request in writing to the Privacy Officer. Your request must state a time
period, which may not be longer than six years and may not include dates
before April 14, 2003. Your request should indicate in what form you want
the list, 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 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 information
we disclose about you to someone who is involved in your care or the payment
for your care, such as a family member or friend. 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 you emergency treatment. To
request restrictions, you must make your request in writing to the Privacy
Officer. In your request, 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 request that we communicate with you about health
matters in a certain way or at a certain location. For example, you can ask
that we only contact you at work or by mail. To request confidential
communications, you must make your request in writing to the Privacy
Officer. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or where
you wish to be contacted.
Right to a Paper Copy of This Notice:
You have the right to a paper copy of this Notice at any time. Even if you
have agreed to receive this Notice electronically, you are still entitled to
a paper copy of this Notice. (1) You may obtain a copy of this Notice at
our website: http://www.rcskids.org, or (2) You may obtain a paper copy of
this Notice by phoning our Privacy Officer at (408) 846-2100. A copy of our
Privacy Notice is also available at the front desk.
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 information we already have
about you as well as any information we receive in the future. We will post
a copy of the current Notice in all RCS sites. The Notice will contain the
effective date on the first page, in the top right-hand corner. In
addition, each time you register at, or are admitted to, RCS for treatment
or services as an inpatient or outpatient, we will offer you a copy of the
current Notice in effect.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a
complaint with RCS or with the Secretary of the Department of Health and
Human Services, Washington, DC. To file a complaint with RCS, contact the
Privacy Officer at (408) 846-2100 or send to: Privacy Officer, Rebekah
Children's Services, 290 IOOF Avenue, Gilroy, CA 95020. All complaints
must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF INFORMATION:
Other uses and disclosures of information not covered by this Notice or the
laws that apply to us, will be made only with your written permission. If
you provide us permission to use or disclose 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 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.
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