Effective Date: September 23, 2013
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.
The entities listed below and their affiliated clinics and institutes of care (“We”) will follow the terms of this Notice and will only use or disclose your health information as is described in this Notice. We are an organized health care arrangement and for purposes of our privacy practices, are considered one single entity, the Loma Linda University Health Organized Health Care Arrangement (“LLUH Organized Health Care Arrangement” or “LLUH OHCA”). A detailed listing of the affiliated clinics and institutes of care affected by this Notice is provided on page 12 in a section titled “Entities That Are Included in the LLUH Organized Health Care Arrangement”.
LOMA LINDA UNIVERSITY
LOMA LINDA UNIVERSITY HEALTH CARE
LOMA LINDA UNIVERSITY FACULTY PRACTICE PLAN
LOMA LINDA UNIVERSITY MEDICAL CENTER
LOMA LINDA UNIVERSITY MEDICAL CENTER - MURRIETA
LOMA LINDA UNIVERSITY CHILDREN’S HOSPITAL
LOMA LINDA UNIVERSITY MEDICAL CENTER EAST CAMPUS
LOMA LINDA UNIVERSITY BEHAVIORAL MEDICINE CENTER
The terms “use” and “disclosure” will be referenced frequently throughout this Notice. As you read this Notice, understand that “use” applies only to activities within our entity and “disclosure” applies to activities such as releasing, transferring, or providing access to information about you to other parties outside our entity.
We know that health information about you is personal and we are committed to protecting the privacy of your information. As a patient, the care and treatment you receive is recorded in a health record. So that we can best meet your health care needs, we may share your record with the health care providers involved in your care for treatment, payment, and health care operations purposes.
For any other reason besides treatment, payment, and health care operations, we can not share your information without your written permission unless the law specifically permits or requires that we do so. For example, in most circumstances, laws pertaining to mental health and substance abuse related services require that we obtain your written permission.
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the following rights regarding health information we maintain about you:
You have the right to request a list (called an Accounting of Disclosures) of certain disclosures that we made about you. All disclosures that are required to be listed by law will appear on the Accounting of Disclosures list. The items that typically would be listed on an Accounting of Disclosures list are indicated in the section titled “How We May Use and Disclose Health Information About You”.
Your request must state a time period for which you are requesting the information, however we are not required to provide an accounting for disclosures made earlier than six (6) years from the date of your request. To request an Accounting of Disclosures, you must submit your request in writing to the department/address listed in the “Contact Information” section on page 11. The first request for an accounting in any 12 month period is provided to you free of charge. Any subsequent requests within that 12 month period may be subject to reasonable fees allowed by law.
For example, if you need follow up care that involves or discusses the services for which you had previously self- paid in full out-of-pocket, that information may be noted in your chart by the treating physician and subsequently sent to your health plan, unless you request in writing that you want to restrict the disclosure of that follow up care and self-pay in full prior to the items or services being provided to you.
Information about items or services you plan to have at one of our facilities may be disclosed to your health plan during verification of health plan/insurance eligibility (i.e., authorization), unless you notify us ahead of time of your intention to submit a written request for restriction of disclosure and self-pay for such items or services.
You have the right to be notified upon a breach of unsecured health information. Health information is “unsecured” if it is not protected by a technology or methodology specified by the Secretary of the U.S. Department of Health and Human Services. The notice must be made within the timeframe specified by federal or state breach notification laws, whichever is more stringent. We must notify you in writing by first class mail. However, we may give telephonic notice to you if we reasonably believe there is a possibility of imminent misuse of your unsecured health information; however, such telephonic notice will not substitute for our written notice obligations.
You have the right to request communications of your health information by alternative means or at alternative locations. We may require requests to be made in writing. We may not require you to provide an explanation of the basis for your request as a condition of providing such communications to you.
You have the right to adequate notice of how we use and disclose your health information. The Notice (or Notice of Privacy Practices) must also advise you of your rights and our legal duties with respect to your health information. You have the right to receive a paper copy of the Notice upon request. A copy of the Notice currently in effect will be available through your health care provider.
Generally, we can only disclose information in your record 1) with your permission, 2) for your treatment, or 3) if federal, state or local law tells us that we can or must disclose information in your record. We can or must disclose information in your record for the purposes listed in this section. When a federal, state or local law tells us that we can or must disclose information in your record, in certain cases, we will list these disclosures in a report if requested. Page 3, under the section titled “Right to an Accounting of Disclosures” explains how you can request a list of these disclosures. The disclosures described below that will typically be listed on an Accounting of Disclosures are noted with the statement “Included in an Accounting of Disclosures”.
For example: We may use or disclose health information about you to doctors, nurses, technicians, students, or other hospital personnel who are involved in taking care of you.
Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We may also provide your treating physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you.
For example: We may use or disclose health information about you so that the treatment and services you receive may be billed to your health plan or health insurance and payment may be collected from you, your insurance company or a third party. For example, we may need to give your health plan information about a surgical procedure you had so your health plan will pay us or reimburse you for the surgery. We may also inform 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. Refer to page 3 for information on how you may request restriction of disclosure to health plans.
For example: Members of the medical and clinical staff, the risk or quality improvement manager, or members of the quality improvement team, may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and service we provide. We may also use or disclose information to doctors, nurses, technicians, students, other hospital personnel for review and learning purposes, and as necessary to conduct our business operations, to administer the policies and processes of our health staff, and to comply with the laws that govern health care. Other examples of how we may use or disclose your health information for health care operations include using or disclosing information for compliance and audit activities, customer service initiatives, and the coordination or provision of spiritual care services.
When you are an inpatient in our facility, we may provide your location in the facility and your general condition to someone who calls and asks for you by name. If you tell us your religious affiliation, we may provide your name, location in the facility, general condition, and religious affiliation to members of the clergy. You can request a restriction on the use and disclosure of your health information for the facility directory by “opting out” or requesting that we do not include any or all of your information in the facility directory. To “opt out” of the facility directory, you must make your request in writing through the Admitting or Registration desk.
Communication with Individuals Involved in Your Care
We may use or disclose information regarding your location and general condition to notify or assist in notifying a family member, personal representative, or another person responsible for your care. Health professionals, using their best judgment, may disclose to individuals such as family members, other relatives, close personal friends or any other individuals involved in your care, health information about you that is relevant to that person’s involvement in your care. We may share portions of your health information to someone responsible for payment related to your care. See page 3 under “Right to Request Restrictions” for information on what to do if you object to our communication with individuals involved in your care.>
Disaster Relief Purposes
In the event of a disaster, we may share your information with other health care professionals, government representatives, or disaster-relief organizations such as the Red Cross, to the extent that it is necessary to respond to the emergency situation so they can coordinate disaster-relief efforts.
We may use or disclose information to researchers when their research has been approved by an Institutional Review Board (IRB) or Privacy Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also use or disclose information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the facility. Your physician or other caregiver may discuss the possibility of enrolling you in a clinical trial. Disclosures made outside our institution for an IRB/Privacy Board approved research activity where your individual permission is not given, are Included in an Accounting of Disclosures.
Health Information Exchanges
Information that requires additional consent in order to be shared includes psychotherapy notes, treatment for substance or alcohol abuse, and records of tests or treatment for sexually transmitted diseases.
California Immunization Registry (CAIR)
As the primary teaching site for Loma Linda University, residents, fellows, and students
in medicine, dentistry, nursing, pharmacy, allied health and other graduate studies, may be assisting with your care under the supervision of a licensed health care provider as a part of their professional health care training program.
We may use or disclose your health information to contact you as a reminder that you have an appointment for treatment or health care.
Incidental Uses and Disclosures
There are certain incidental uses or disclosures of your health information that occur while we are providing services to you or conducting our business. For example, after surgery the nurse or doctor may need to use your name to identify family members that may be waiting for you in a waiting area, other individuals waiting in the same area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.
We may use or disclose health 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 health information to tell you about our health-related products or services that may be of interest to you.
We may contact you as part of a fund-raising effort to expand and support health care services, educational programs, and research activities related to curing disease. We may use your name, address, and other limited information allowed by law such as dates on which we provided health care to you in order to contact you and provide you with an opportunity to make a donation to our fund raising programs. We do not access or use your diagnosis or treatment information for fundraising activities, unless we have your written authorization to do so.
We will not sell, trade, or loan your information to any third parties, but we may share it with closely related foundations and business associates that assist us in our development activities.
Any fundraising communications you receive from us or one of our foundations will include information on how you may opt out from receiving any further fundraising communications.
Medical Staff Administration
The Medical Staff is responsible for insuring appropriate conduct of physicians and other licensed health professionals in the provision of patient care and safety within our facilities. It is sometimes necessary for the Medical Staff administrators and committees to conduct an internal review of patient records to insure quality care by the professionals privileged to practice in our facilities.
Use or Disclosure Required by Law
We will disclose health information about you when required to do so by federal, state or local law.
As required by law, we may disclose your health information to public health or legal authorities for activities that include but are not limited to the following: (a) to prevent or control disease, injury or disability; (b) to report births and deaths; (c) to report the abuse or neglect of children, elders and dependent adults; (d) to report reactions to medications or problems with products;(e) to notify people of recalls of products they may be using; (f) 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; (g) 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. (Included in an Accounting of Disclosures)
Food and Drug Administration (FDA)
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. (Included in an Accounting of Disclosures)
We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. (Included in an Accounting of Disclosures)
Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law. Health oversight agencies include the Department of Health Services (DHS) and the Department of Health and Human Services (HHS). Oversight activities include, for example, audits, investigations, inspections and licensure. (Included in an Accounting of Disclosures)
Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. (Included in an Accounting of Disclosures)
Lawsuits and Disputes
If you are involved in a lawsuit or 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, 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 by that person, (e.g., notice to consumer), which would give you an opportunity to obtain an order protecting the information requested. (Included in an Accounting of Disclosures)
To Avert a Serious Threat to Health or Safety
We may use and disclose health 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. (Included in an Accounting of Disclosures)
Coroners, Medical Examiners, and Funeral Directors
Consistent with applicable law, we may disclose your health information to funeral directors to carry out their duties. (Included in an Accounting of Disclosures)
Organ, Eye, and Tissue Procurement Organizations
Consistent with applicable law, we may disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs and/or tissues for the purpose of tissue donation and transplant. (Included in an Accounting of Disclosures)
We are not permitted to provide your health information to any other person or company for marketing to you of any products or services, unless with your express written authorization. We are also not permitted to receive payment in exchange for making such marketing communication to you. We may, however, provide you with marketing materials in a face-to-face encounter without obtaining your authorization. In addition, we may tell you about our own health care products and services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without obtaining your authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining your authorization.
Sale of Health Information
We are not permitted to receive payments for the sale of your health information, unless we receive express authorization from you. Such authorization will state that the disclosure will result in remuneration to our organization.
Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including genetic information. For example, we might talk to your provider to suggest a disease management or wellness program that could help improve your health however; we will not use or disclose your genetic information for underwriting purposes.
There are some services provided in our entity through contracts with business associates. An example is a transcription service we may use for transcribing physician dictation of your health record. Another example is the conducting of patient satisfaction surveys for quality improvement purposes. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require our business associates, through contract, to appropriately safeguard the privacy of your health information. In addition, these business associates are also governed by federal law and required to comply directly with provisions related to the maintenance of your health information in a confidential manner.
Other Uses and Disclosures
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 permission (e.g., most uses and disclosures of psychotherapy notes). Disclosures made with your written permission will not be included on the Accounting of Disclosures as you will already have record of these. If you provide us permission to use or disclose health 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 health 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.
This LLUH OHCA is required to:
We reserve the right to change the terms of this notice and to make the new provisions effective for health information we maintain. We will post a copy of the current notice at each affiliated site and on our website. The notice will contain its effective date in the top right-hand corner of its first page.
If you believe your privacy rights have been violated, you may file a complaint. To file a complaint, contact the Patient Relations representative listed in the Contact Information section on this page. All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. Our Patient Relations representative can provide you with the appropriate address upon request.
IMPORTANT CONTACT INFORMATION
|Contact Person or
* Requests to Access, Inspect and Obtain Copy of Health and/or Billing Record
* Requests for an Accounting of Disclosures
* Requests to Amend your Health and/or Billing Record
| 101 East Redlands
Blvd. Suite 1200
San Bernardino, CA
|LLUHC-Faculty Groups Health Information Management
101 East Redlands
Blvd. Suite 1100
San Bernardino, CA
|LLU Medical Center – Murrieta
28078 Baxter Road Suite
Murrieta, CA 92563
1710 Barton Road
Redlands, CA 92374
See list of LLU Clinics and addresses below
|SAC Health System
1454 East Second Street
San Bernardino, CA
|* Request for Restrictions||Make request directly to your health care provider. If you
are an inpatient, you can also make your request to the Admitting or Registration Desk.
|* Requests for Alternate
Means of Communication
|Make request directly to your health care provider|
|* Complaints (in writing)||LLU Medical Center
11234 Anderson Street
Loma Linda 92354
11370 Anderson Street
Loma Linda, CA 92354
|LLU Medical Center – Murrieta
28062 Baxter Road
Murrieta, CA 92563
1710 Barton Road
Redlands, CA 92374
LLU Clinics SAC Health System
1454 East Second St.
San Bernardino, CA
|Privacy Complaint Telephone
|Contact Information for LLU Clinics|
|Center for Health Promotion
|Evans Hall, 24785 Stewart Street, Loma Linda, CA
|School of Dentistry||11092 Anderson Street, Loma Linda, CA 92354||909-558-4222|
Loma Linda University Medical Center(to include but not limited to)
Loma Linda University Children’s Hospital
Loma Linda University Medical Center – Murrieta
Loma Linda University Behavioral Medicine Center
Loma Linda University Health Care
Loma Linda University Faculty Practice Plan
Loma Linda University
Behavioral Health Institute (BHI)
Social Action Community Health System (SACHS)
Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by accessing our web site at www.llu.edu or contacting the Privacy Office at (909) 558-6460.
If you have any questions about our Notice of Privacy Practices, please contact the Privacy Office at (909) 558-6460.