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Please contact our Privacy Officer at (323) 766-2360
ext. 3305, if you have any questions.
I. Introduction
This Notice of Privacy Practices describes how we may use
and disclose your protected health information to carry out
treatment, payment or health care operations and for other
purposes that are permitted or required by law. This Notice
also describes your rights regarding health information we
maintain about you and a brief description of how you may
exercise these rights. This Notice further states the
obligations we have to protect your health information.
“Protected health information,” means health
information, including identifying information about you,
we have collected from you or received from your health care
providers, health plans, your employer or a health care clearinghouse. It
may include information about your past, present or future
physical or mental health or condition, the provision of
your health care, and payment for your health care services.
We are required by law to maintain the privacy of your health
information and to provide you with this notice of our legal
duties and privacy practices with respect to your health
information. We are also required to comply with the
terms of our current Notice of Privacy Practices.
II. How We Will Use and Disclose
Your Health Information
We will use and disclose your health information as described
in each category listed below. For each category, we
will explain what we mean in general, but not describe all
specific uses or disclosures of health information.
A. Uses and Disclosures for Treatment,
Payment and Operations
1. For
Treatment. As stated in your Consent
for Treatment, we will use and disclose your health
information to provide your health care and any related
services. We
will also use and disclose your health information
to coordinate and manage your health care and related
services. For
example, we may need to disclose information to another
provider for the purpose of coordinating your care. We
may also disclose your health information among our
clinicians and other staff, e.g. supervisors, program
staff, family advocates, and psychiatrists. For
example, our staff may discuss your care at a case
conference. In
addition, as part of the Los Angeles County mental
health system, we may disclose your health information
without your authorization to another health care provider
(e.g., other department providers, your primary care
physician or a laboratory) working outside of the Clinicfor
purposes of your treatment.
2. For Payment. We may
use or disclose your health information without your authorization
so that the treatment and services you receive are billed
to, and payment is collected from, your health plan or other
third party payer. For example, we may disclose your
health information to verify your healthcare benefit eligibility
or follow-up on payment for our services. These
actions may include, but are not limited to:
- Making a determination of eligibility or coverage
for health insurance;
- Reviewing your services to determine if they were
medically necessary;
- Reviewing your services to determine if they were
appropriately authorized or certified in advance
of your care; or
- Reviewing your services for purposes of utilization
review, to ensure the appropriateness of your
care, or to justify the charges for your care
For example, your local County or private health plan
may ask us to share your health information in order
to determine if additional services will be approved. We
may also disclose your health information to another
health care provider so that provider can bill you for
services they provided to you, for example an ambulance
service that transported you to the hospital.
3. For Health Care Operations. We
may use and disclose health information about you without
your authorization for our health care operations. These
uses and disclosures are necessary to run our organization
and make sure that our consumers receive quality care. These
activities may include, for example, quality management
and improvement, reviewing the performance or qualifications
of our clinicians, training students in clinical activities,
licensing, accreditation, business planning and development,
and general administrative activities. We may combine
health information of many of our clients to decide what
additional services we should offer, what services are
no longer needed, and whether certain treatments are
effective.
We may also provide your
health information to other health care providers or
to your health plan to assist them in performing certain
of their own health care operations. We will do so only
if you receive or have received services from the other
provider or health plan. For example, we may provide
information about you to the your local County or private
health plan to assist them in their quality assurance
activities.
We may also use and disclose
your health information to contact you to remind you
of your appointment.
Finally,
we may use and disclose your health information to inform
you about possible treatment options or alternatives
that may be of interest to you at the Clinic.
4. Health-Related Benefits
and Services. We
may use and disclose health information to send you about
health-related benefits or services that may be of interest
to you. If you do not want us to provide you with
information about health-related benefits or services,
you must notify the Privacy Officer in writing at Los
Angeles Child Guidance Clinic, 3031 S. Vermont Ave.,
Los Angeles, CA, 90007. Please state clearly that you
do not want to receive materials about health-related
benefits or services.
B. Uses and Disclosures That May
be Made Without Your Authorization, But For Which You Will
Have an Opportunity to Object.
1. Persons
Involved in Your Care. We may provide
health information about you to someone who helps pay
for your care. We may use or disclose your health
information to notify or assist in notifying a family
member, personal representative, public guardian or
conservator or any other person that is responsible
for your care of your location, general condition or
death. We may also use or
disclose your health information to an entity assisting
in disaster relief efforts and to coordinate uses and
disclosures for this purpose to family or other individuals
involved in your health care.
In limited
circumstances, we may disclose health information about
you to a family member or friend who is involved in your
care. If
you are physically present and have the capacity to make
health care decisions, your health information may only
be disclosed with your agreement to persons you designate
to be involved in your care.
But, if you are in an
emergency situation, we may disclose your health information
to a spouse, a family member, or a friend so that such
person may assist in your care. In this case we will
determine whether the disclosure is in your best interest
and, if so, only disclose information that is directly
relevant to participation in your care.
And, if you are not in
an emergency situation but are unable to make health
care decisions, we will disclose your health information
to:
- A person designated to participate in your care in
accordance with an advance directive validly executed
under state law,
- Your guardian or other fiduciary if one has been
appointed by a court, or
- If applicable, the state agency responsible for consenting
to your care.
C. Uses and Disclosures That
May be Made Without Your Authorization or Opportunity
to Object.
1. Emergencies. We may use and disclose
your health information in an emergency treatment situation. By
way of example, we may provide your health information to
a paramedic who is transporting you in an ambulance. If
you are court ordered to receive treatment and your treating
clinician has attempted to obtain your authorization
but is unable to do so, the treating clinician may nevertheless
use or disclose your health information to treat you.
2. Research. We may disclose your
health information to researchers when their research has
been approved by the Clinic’s Institutional Review
Board that has reviewed the research proposal and established
protocols to protect the privacy of your health information.
3. As Required By Law. We will
disclose health information about you when required to
do so by federal, state or local law.
4. To Avert a Serious Threat to Health
or Safety. We
may use and disclose health information about you when necessary
to prevent a serious and imminent threat to your health or
safety or to the health or safety of the public or another
person. Under these circumstances, we will only
disclose health information to someone who is able to
help prevent or lessen the threat.
5. Organ and Tissue Donation. If
you are an organ donor, we may release your health information
to an organ procurement organization or to an entity
that conducts organ, eye or tissue transplantation, or
serves as an organ donation bank, as necessary to facilitate
organ, eye or tissue donation and transplantation.
6. Public Health Activities. We
may disclose health information about you as necessary
for public health activities including, by way of example,
disclosures to:
- Report to public health authorities for the purpose
of preventing or controlling disease, injury or
disability;
- Report vital events such as birth or death;
- Conduct public health surveillance or investigations;
- Report certain events to the Food and Drug Administration
(FDA) or to a person subject to the jurisdiction
of the FDA including information about defective
products or problems with medications;
- Notify consumers about FDA-initiated product recalls;
- Notify a person who may have been exposed to a communicable
disease or who is at risk of contracting or
spreading a disease or condition;
- Notify the appropriate government agency if we believe
you have been a victim of elder/dependent adult
abuse and/or neglect
7. Health
Oversight Activities. We
may disclose health information about you to a health
oversight agency for activities authorized by law. Oversight
agencies include government agencies that oversee the
health care system, government benefit programs such
as Medicare or Medicaid, other government programs regulating
health care, and civil rights laws.
8. Disclosures in Legal Proceedings. We
may disclose health information about you to a court or administrative
agency when a judge or administrative agency orders us to
do so. We also may disclose health information about
you in legal proceedings without your permission or without
a judge or administrative agency’s order when we
receive a subpoena for your health information.
9. Law Enforcement Activities. We
may disclose health information to a law enforcement
official for law enforcement purposes when:
- A court order, subpoena, warrant, summons or similar
process requires us to do so; or
- The information is needed to identify or locate a
suspect, fugitive, material witness or missing person;
or
- We report a death that we believe may be the result
of criminal conduct; or
- We report criminal conduct occurring on the premises
of our facility; or
- We determine that the law enforcement purpose is
to respond to a threat of an imminently dangerous activity
by you against yourself or another person; or
- The disclosure is otherwise required by law.
We may also disclose health information about a client
who is a victim of a crime, without a court order or
without being required to do so by law. However, we will do
so only if the disclosure has been requested by a law enforcement
official and the victim agrees to the disclosure or, in the
case of the victim’s incapacity, the following
occurs:
- The law enforcement official represents to us that (i)
the victim is not the subject of the investigation and
(ii) an immediate law enforcement activity to meet a serious
danger to the victim or others depends upon the disclosure;
and
- We determine that the disclosure is in the victim’s
best interest.
10. Medical Examiners or Funeral Directors. We
may provide health information about our consumers to a medical
examiner. Medical examiners are appointed by
law to assist in identifying deceased persons and to determine
the cause of death in certain circumstances. We
may also disclose health information about our consumers
to funeral directors as necessary to carry out their
duties.
11. Military
and Veterans. If
you a member of the armed forces, we may disclose your
health information as required by military command authorities. We
may also disclose your health information for the purpose
of determining your eligibility for benefits provided by
the Department of Veterans Affairs. Finally, if
you are a member of a foreign military service, we may
disclose your health information to that foreign military
authority.
12. National
Security and Protective Services for the President
and Others. We may
disclose medical information about you to authorized
federal officials for intelligence, counter-intelligence,
and other national security activities authorized by
law. We may also
disclose health information about you to authorized
federal officials so they may provide protection to
the President, other authorized persons or foreign
heads of state or so they may conduct special investigations.
13. Inmate/Probation Clients. If
you are an inmate or under the custody of a law enforcement
official (i.e. on probation), we may disclose health
information about you to the correctional institution
or law enforcement official.
14. Workers’ Compensation. We
may disclose health information about you to comply with
Workers’ Compensation Law.
III. Uses and Disclosures of Your
Health Information with Your Permission.
Uses and disclosures not described in Section II of this
Notice of Privacy Practices will generally only be made with
your written permission, called an “authorization.” You
have the right to revoke an authorization at any time. If
you revoke your authorization we will not make any further
uses or disclosures of your health information under that
authorization, unless we have already taken an action relying
upon the uses or disclosures you have previously authorized.
IV. Your Rights Regarding Your
Health Information.
A. Right to Inspect and Copy.
You have the right to request an opportunity to inspect
or copy health information used to make decisions about
your care – whether they are decisions about your treatment
or payment of your care. Usually, this would include
clinical and billing records, but not psychotherapy notes.
You must submit your request in writing to our Privacy
Officer at Los Angeles Child Guidance Clinic, 3031 S. Vermont
Ave., Los Angeles, CA 90007. If
you request a copy of the information, we may charge a
fee for the cost of copying, mailing and supplies associated
with your request.
We may deny your request to inspect or copy your health
information in certain limited circumstances. In some
cases, you will have the right to have the denial reviewed
by a licensed health care professional not directly involved
in the original decision to deny access. We will inform
you in writing if the denial of your request may be reviewed. Once
the review is completed, we will honor the decision made
by the licensed health care professional reviewer.
B. Right to Amend.
For as long as we keep records about you, you have the
right to request us to amend any health information used
to make decisions about your care – whether they are
decisions about your treatment or payment of your care. Usually,
this would include clinical and billing records, but not
psychotherapy notes.
To request an amendment, you must submit a written document
to our Privacy Officer at Los Angeles Child Guidance Clinic,
3031 S. Vermont Ave., Los Angeles, CA 90007and tell
us why you believe the information is incorrect or inaccurate.
We may deny your request for an amendment if it is not
in writing or does not include a reason to support the
request. We
may also deny your request if you ask us to amend health
information that:
- Was not created by us, unless the person or entity
that created the health information is no longer available
to make the amendment;
- Is not part of the health information we maintain to
make decisions about your care;
- Is not part of the health information that you would
be permitted to inspect or copy; or
- Is accurate and complete.
If we deny your request to amend, we will send you a written
notice of the denial stating the basis for the denial and
offering you the opportunity to provide a written statement
disagreeing with the denial. If you do not wish to
prepare a written statement of disagreement, you may ask
that the requested amendment and our denial be attached
to all future disclosures of the health information that
is the subject of your request.
If you choose to submit a written statement of disagreement,
we have the right to prepare a written rebuttal to your
statement of disagreement. In this case, we will
attach the written request and the rebuttal (as well as
the original request and denial) to all future disclosures
of the health information that is the subject of your request.
C. Right to an Accounting of Disclosures.
You have the right to request that we provide you with
an accounting of disclosures we have made of your health
information. An
accounting is a list of disclosures. But this list
will not include certain disclosures of your health information,
for example, those we have made for purposes of treatment,
payment, and health care operations.
To request an accounting of disclosures, you must submit
your request in writing to the Privacy Officer at Los Angeles
Child Guidance Clinic, 3031 S. Vermont Ave., Los Angeles,
CA 90007. For your convenience,
you may submit your request on a form called a “Request
For Accounting,” which you may obtain from our Privacy
Officer. The request should state the time period
for which you wish to receive an accounting. This time
period should not be longer than six years and not include
dates before April 14, 2003.
The first accounting you request within a twelve-month
period will be free. For additional requests during the same
12-month period, we will charge you for the costs of providing
the accounting. We will notify you of the amount
we will charge and you may choose to withdraw or modify
your request before we incur any costs.
D. Right to Request Restrictions.
You have the right to request a restriction on the health
information we use or disclose about you for treatment,
payment or health care operations. To request a restriction,
you must request the restriction at Los Angeles Child Guidance
Clinic, 3031 S. Vermont Ave., Los Angeles, CA 90007.The
Privacy Officer will ask you to sign a request for restriction
form, which you should complete and return to the Privacy
Officer.
We are not required to agree to a restriction that you
may request. If we do agree, we will honor your request
unless the restricted health information is needed to provide
you with emergency treatment.
E. Right to Request Confidential
Communications.
You have the right to request that we communicate with
you about your health care only in a certain location or
through a certain method. For example, you may request
that we contact you only at work or by e-mail.
To request such a confidential communication, you must
make your request in writing to the Privacy Officer at
Los Angeles Child Guidance Clinic, 3031 S. Vermont Ave.,
Los Angeles, CA 90007. We will accommodate all reasonable
requests. You do not need to give us a reason for the
request; but your request must specify how or where you wish
to be contacted.
F. Right to a Paper Copy of this
Notice.
You have the right to obtain a paper copy of this Notice
of Privacy Practices at any time. Even if you have
agreed to receive this Notice of Privacy Practices electronically,
you may still obtain a paper copy. To obtain a paper
copy, contact our Privacy Officer at Los Angeles Child
Guidance Clinic, 3031 S. Vermont Ave., Los Angeles, CA,
90007.
V. Confidentiality of Substance
Abuse Records
For individuals who have received treatment, diagnosis or
referral for treatment regarding drug or alcohol use/abuse,
the confidentiality of drug or alcohol use/abuse records
is protected by federal law and regulations. As a general
rule, we may not tell a person outside the Clinic that you
receive treatment for alcohol/drug use/abuse unless:
- You authorize the disclosure in writing; or
- The disclosure is permitted by a court order; or
- The disclosure is made to medical personnel in a medical
emergency or to qualified personnel for research, audit
or program evaluation purposes; or
- You threaten to commit a crime either at the Clinic or
against any person who works for our Clinic.
A violation by us of the federal law and regulations governing
drug or alcohol abuse is a crime. Suspected violations
may be reported to the Unites States Attorney in the district
where the violation occurs. Federal law and regulations
governing confidentiality of drug or alcohol abuse permit
us to report suspected child, elder, or dependent adult abuse
or neglect under state law to appropriate state or local
authorities. Please see 42 U.S.C. § 290dd-2 for
federal law and 42 C.F.R., Part 2 for federal regulations
governing confidentiality of alcohol and drug abuse patient
records.
VI. Complaints
If you believe your privacy rights have been violated, you
may file a complaint with us or with the Secretary of the
U.S. Department of Health and Human Services. To file
a complaint with us, contact: Complaint Officer,Los
Angeles Child Guidance Clinic, 3031 S. Vermont Ave., Los
Angeles, CA, 90007, and (323) 766-2360 ext. 3397. All
complaints must be submitted in writing.
Our Privacy Office, which can be contacted at Los Angeles
Child Guidance Clinic, 3031 S. Vermont Ave., Los Angeles,
CA, 90007, will assist you with writing
your complaint, if you request such assistance.
We will not retaliate against you for filing a complaint.
VII. Changes to this Notice
We reserve the right to change the terms of our Notice of
Privacy Practices. We also reserve the right to make
the revised or changed Notice of Privacy Practices effective
for all health information we already have about you as well
as any health information we receive in the future. We
will post a copy of the current Notice of Privacy Practices
at our main office and at each site where we provide care. You
may also obtain a copy of the current Notice of Privacy Practices
by accessing our website at www.lacgc.org or by calling us
at (323) 766-2360 ext. 3397 requesting that a copy be sent
to you in the mail or by asking for one any time you are
at our offices.
Adopted 3-20-03
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