Notice of Privacy Practices
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.
I. Who We Are
This Notice describes the privacy practices of Optimist Youth Homes &
Family Services, its therapists, contract staff, youth care counselors, nurses,
administrative staff and all other personnel. It applies to services furnished to
you at all our sites.
II. Our Privacy Obligations
We are required by law to maintain the privacy of your health information
(“Protected Health Information” or “PHI”) and to provide you with this Notice
of our legal duties and privacy practices with respect to your Protected Health
Information. When we use or disclose your Protected Health Information, we
are required to abide by the terms of this Notice (or other notice in effect at
the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must
obtain your written authorization in order to use and/or disclose your PHI.
However, we do not need any type of authorization from you for the following
uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations.
We may use and disclose PHI in order to treat you, obtain payment for services
provided to you and conduct our “health care operations” as described generally
below:
lTreatment. We use and disclose your PHI to provide treatment and other services
to you--for example, to diagnose and treat your behavioral issues. In addition,
we may contact you to provide appointment reminders or information about
treatment alternatives or other health-related benefits and services that may be
of interest to you. We may also disclose PHI to other providers involved in your
treatment.
lPayment. We may use and disclose your PHI to obtain payment for services
that we provide to you--for example, disclosures to claim and obtain payment
from your health insurer, HMO, or other company that arranges or pays the
cost of some or all of your health care (“Your Payor”) or to verify that Your
Payor will pay for health care.
lHealth Care Operations. We may use and disclose your PHI for our health care
operations, which include internal administration and planning and various activities
that improve the quality and cost effectiveness of the care that we deliver to you.
For example, we may use PHI to evaluate the quality and competence of our
therapists and other health care workers. We may share PHI with our program
directors in order to resolve any complaints you may have and ensure that you
have a comfortable visit with us. If complaints go directly to the program directors,
the program directors are required to inform the privacy officer. The privacy officer
keeps a “Log of complaints” in his/ her office.
lOther Providers. We may also disclose PHI to your other health care providers
when such PHI is required for them to treat you, receive payment for services
they render to you, or conduct certain health care operations, such as quality
assessment and improvement activities, reviewing the quality and competence
of health care professionals, or for health care fraud and abuse detection or
compliance.
B. Use or Disclosure of the client roster of Optimist Youth Homes & Family Services.
We may include your name and your location at Optimist Youth Homes & Family
Services, in the client roster without obtaining your authorization. Information in the
roster will not be disclosed, which means that a client’s presence in our programs
is never disclosed unless authorized by law.
C. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or
disclose your PHI to a family member, other relative, a close personal friend or any
other person identified by you when you are present for, or otherwise available prior
to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity
to object to the disclosure and you do not object; or (3) reasonably infer that you do
not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure
cannot practicably be provided because of your incapacity or an emergency
circumstance, we may exercise our professional judgment to determine whether a
disclosure is in your best interests. If we disclose information to a family member,
other relative or a close personal friend, we would disclose only information that we
believe is directly relevant to the person’s involvement with your health care or
payment related to your health care. We may also disclose your PHI in order to notify
(or assist in notifying) such persons of your location, general condition or death.
D. Fundraising Communications. We do not contact you or your parent/guardian to
request a tax-deductible contribution to support important activities of Optimist Youth
Homes & Family Services.
E. Public Health Activities. We may disclose your PHI for the following public health
activities: (1) to report health information to public health authorities for the purpose of
preventing or controlling disease, injury or disability; (2) to report child abuse and neglect
to public health authorities or other government authorities authorized by law to receive
such reports; (3) to report information about products and services under the jurisdiction
of the U.S. Food and Drug Administration.
F. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a
victim of abuse, neglect or domestic violence, we may disclose your PHI to a
governmental authority, including a social service or protective services agency,
authorized by law to receive reports of such abuse, neglect, or domestic violence.
G. Health Oversight Activities. We may disclose your PHI to a health oversight agency
that oversees the health care system and is charged with responsibility for ensuring
compliance with the rules of government health programs such as Medicare or Medicaid.
H. Judicial and Administrative Proceedings. We may disclose your PHI in the course of
a judicial or administrative proceeding in response to a legal order or other lawful process.
I. Law Enforcement Officials. We may disclose your PHI to the police or other law
enforcement officials as required or permitted by law or in compliance with a court order,
or a grand jury or administrative subpoena, or a discovery request.
J. Decedents. We may disclose your PHI to a coroner or medical examiner as
authorized by law.
K. Organ and Tissue Procurement. We may disclose your PHI to organizations that
facilitate organ, eye or tissue procurement, banking or transplantation.
L. Research. We may use your Protected Health Information for research projects.
To do this, we will either ask your permission to use your Protected Health Information
or we will use a special process that protects the privacy of your information. In addition,
we may use information that cannot be identified as your Protected Health Information,
but that includes certain limited information such as your date of birth and dates of
service. We will use this information for research, quality assurance activities and
other similar purposes and we will obtain special protections for the information disclosed.
M. Health or Safety. We may use or disclose your PHI to prevent or lessen a serious
and imminent threat to a person’s or the public’s health or safety.
N. Specialized Government Functions. We may use and disclose your PHI to units
of the government with special functions, such as the U.S. military or the U.S.
Department of State under certain circumstances.
O. Workers’ Compensation. We may disclose your PHI as authorized by and to the
extent necessary to comply with California law relating to workers' compensation or
other similar programs.
P. As required by law. We may use and disclose your PHI when required to do so by
any other law not already referred to in the preceding categories.
Q. Genetic Testing Information. If we keep genetic testing information about you, we will
release that information only to the state departments that monitor our work or if required
by law to release that information. Otherwise, we will give out this information only if you
give us your permission in writing.
R. Communicable Disease Information. If you have a communicable disease, such as
HIV/AIDS, we will provide that information to your health care provider, to providers
engaged in organ procurement, or if required by law. For all other purposes, we will
give out this information only with your permission.
S. Mental Health Information. Special protections apply to inpatient and outpatient
mental health records, including psychotherapy notes. We will only disclose your
mental health information in compliance with these special protections.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the
ones described above in Section III, we only may use or disclose your PHI when
you grant us your written authorization on our authorization form (“Your Authorization”).
For instance, you will need to execute an authorization form before we can send
your PHI to your life insurance company.
B. Marketing. We must also obtain your written authorization (“Your Marketing
Authorization”) prior to using your PHI to send you any marketing materials.
(We can, however, provide you with marketing materials in a face-to-face encounter
without obtaining Your Marketing Authorization. We are also permitted to give you a
promotional gift of nominal value, if we so choose, without obtaining Your Marketing
Authorization.) In addition, we may communicate with you about products or services
relating to your treatment, case management or care coordination, or alternative
treatments, therapies, providers or care settings without Your Marketing Authorization.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your
privacy rights, are concerned that we have violated your privacy rights or disagree
with a decision that we made about access to your PHI, you may contact our Privacy
Officer. You may also file written complaints with the Director of the Office for Civil
Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy
Officer will provide you with the correct address for the Director. We will not retaliate
against you if you file a complaint with the Director or us.
B. Right to Request Additional Restrictions. You may request restrictions on our use and
disclosure of your PHI (1) for treatment, payment and health care operations, (2) to
individuals (such as a family member, other relative, close personal friend or any
other person identified by you) involved with your care or with payment related to your
care, or (3) to notify or assist in the notification of such individuals regarding your
location and general condition. While we will consider all requests for additional
restrictions carefully, we are not required to agree to a requested restriction. If you
wish to request additional restrictions, please obtain a request form from our Privacy
Officer and submit the completed form to the Privacy Officer. We will send you a
written response.
C. Right to Receive Confidential Communications. You may request to receive your
PHI by alternative means of communication or at alternative locations. For example,
you can request that we only contact you at work or by mail. To request confidential
communications, you must make your request in writing. We will not ask you for the
reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your
Marketing Authorization or any written authorization obtained in connection with
your Highly Confidential Information, except to the extent that we have taken action
in reliance upon it, by delivering a written revocation statement to the Privacy Officer
identified below. A form of Written Revocation is available upon request from the
Privacy Officer.
E. Right to Inspect and Copy Your Health Information. You may request access to
your medical record file and billing records maintained by us. You may inspect and
request copies of the records. Under limited circumstances, we may deny you
access to a portion of your records. If you desire access to your records, please
obtain a record request form from the Privacy Officer and submit the completed
form to the Privacy Officer. If you request copies, we will charge you $0.25
(Twenty-five cents) for each page. We will also charge you for our postage costs,
if you request that we mail the copies to you.
You should take note that, if you are a parent or legal guardian of a minor, certain
portions of the minor’s medical record will not be accessible to you (for example,
records pertaining to health care services for which the minor can lawfully give
consent and therefore for which the minor has the right to inspect or obtain copies
of the record; or the health care provider determines, in good faith, that access to
the client records requested by the representative would have a detrimental effect
on the provider's professional relationship with the minor client or on the minor's
physical safety or psychological well-being.)
F. Right to Amend Your Records. You have the right to request that we amend
Protected Health Information maintained in your medical record file or billing records.
If you desire to amend your records, please obtain an amendment request form
from the Privacy Officer and submit the completed form to the Privacy Officer.
We will comply with your request unless we believe that the information that
would be amended is accurate and complete or other special circumstances apply.
G. Right to Addendum. You have the right to add a 250-word document
(“addendum”) to your medical record.
H. Right to Receive An Accounting of Disclosures. Upon request, you may
obtain an accounting of certain disclosures of your PHI made by us during any
period of time prior to the date of your request provided such period does not
exceed six years and does not apply to disclosures that occurred prior to
April 14, 2003. If you request an accounting more than once during a twelve
(12) month period, we will charge you $0.25 (Twenty-five cents) per page of the
accounting statement. If you desire to make a request for an accounting of
disclosures, please obtain an accounting request form from the Privacy Officer
and submit the completed form to the Privacy Officer.
I. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a
paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice
at any time. If we change this Notice, we may make the new notice terms effective
for all Protected Health Information that we maintain, including any information created
or received prior to issuing the new notice. If we change this Notice, we will post the
new notice in reception/ waiting areas at all operation and office sites of Optimist Youth
Homes & Family Services and on our Internet site at www.oyhfs.org. You also may
obtain any new notice by contacting the Privacy Officer.
VII. Privacy Officer
You may contact the Privacy Officer at:
Quality Improvement Department (Privacy Officer)
Optimist Youth Homes & Family Services
6957 North Figueroa Street
Los Angeles, CA 90042
Telephone Number: (323) 443-3180
E-mail: mbhattachan@oyhfs.org