P. O. Box 70, Lake Arrowhead, CA 92352
(909) 336-3651

NOTICE OF PRIVACY PRACTICES

 AS OF APRIL 14, 2003, UNDER FEDERAL LAW, THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) COVERED HEALTH CARE ORGANIZATIONS ACROSS THE NATION, INCLUDING MOUNTAINS COMMUNITY HOSPITAL (MCH), MUST HAVE A “NOTICE OF PRIVACY PRACTICES” AND PROVIDE PATIENTS WITH A COPY.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW CAREFULLY.

If you have any questions about this notice, please contact Jim Hoss, Executive Director, Mountains Community Hospital,  P.O. Box 70, Lake Arrowhead, CA 92352.

WHO WILL FOLLOW THIS NOTICE

This notice describes MCH’s practices and that of:

• Any health care professional authorized to enter information into your medical record.
• All departments and units of MCH.
• Any member of a volunteer group MCH allows to help you while you are in MCH.
• All employees, staff and other MCH personnel.

OUR PLEDGE REGARDING MEDICAL INFORMATION

MCH understands that medical information about you and your health is personal.  MCH is committed to protecting medical information about you.  MCH creates a record of the care and services you receive at MCH.  MCH needs 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 MCH, whether made by MCH personnel or your personal doctor.  Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which MCH may use and disclose medical information about you.  MCH also describes your rights and certain obligations MCH has regarding the use and disclosure of medical information.

MCH is required by law to:

• Make sure that medical information that identifies you is kept private (with certain exceptions);
• Give you this notice of MCH’s legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

HOW MCH MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that MCH uses and discloses medical information.  For each category of uses or disclosures MCH will explain what MCH means and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways MCH is permitted to use and disclose information will fall within one of the categories.

For Treatment.

MCH may use medical information about you to provide you with medical treatment or services.  MCH may disclose medical information about you to doctors, nurses, technicians, medical students, or other MCH personnel who are involved in taking care of you at MCH.  For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals.  Different departments of MCH also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.  MCH also may disclose medical information about you to people outside MCH who may be involved in your medical care after you leave MCH, such as skilled nursing facilities or home health agencies.

For Payment.

MCH may use and disclose medical information about you so that the treatment and services you receive at MCH may be billed to and payment may be collected from you, an insurance company or a third party.  For example, MCH may need to give your health plan information about surgery you received at MCH so your health plan will pay us or reimburse you for the surgery.  MCH 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.

MCH may use and disclose medical information about you for health care operations.  These uses and disclosures are necessary to run MCH and make sure that all of our patients receive quality care.  For example, MCH may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.  MCH may also combine medical information about many hospital patients to decide what additional services MCH should offer, what services are not needed, and whether certain new treatments are effective.  MCH may also disclose information to doctors, nurses, technicians, medical students, and other MCH personnel for review and learning purposes.  MCH may also combine the medical information MCH has with medical information from other hospitals to compare how MCH is doing and see where MCH can make improvements in the care and services MCH offers.  MCH may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders.

MCH may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at MCH

Treatment Alternatives.

MCH may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Products and Services.

MCH may use and disclose medical information to tell you about MCH’s health-related products or services that may be of interest to you.

Fundraising Activities.

MCH may use medical information about you to contact you in an effort to raise money for MCH and its operations.  MCH may disclose medical information to a foundation related to MCH so that the foundation may contact you in raising money for MCH.  MCH only would release contact information, such as your name, address and phone number and the dates you received treatment or services at MCH.  If you do not want MCH to contact you for fundraising efforts, you must notify the MCH Executive Director in writing.

Individuals Involved in Your Care or Payment for Your Care.

MCH may release medical information about you to a friend or family member who is involved in your medical care.  MCH may also give information to someone who helps pay for your care.  Unless there is a specific written request from you to the contrary, MCH may also tell your family or friends your condition and that you are in MCH.  In addition, MCH may disclose medical 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, MCH may use and disclose medical information about you for research purposes.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval proves.  This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information.  Before MCH uses or discloses medical information for research, the project will have been approved through this research approval process, but MCH may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave MCH.  MCH will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at MCH.

As Required By Law.

MCH will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety.

MCH may use and disclose medical 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

Organ and Tissue Donation.

MCH may release medical 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.

Military and Veterans.

If you are a member of the armed forces, MCH may release medical information about you as required by military command authorities.  MCH may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation.

MCH may release medical information about you for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illness.

Public Health Risks.

MCH may disclose medical 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 MCH believes a patient has been the victim of abuse, neglect or domestic violence.  MCH will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities.

MCH may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes.

If you are involved in a lawsuit or a dispute, MCH may disclose medical information about you in response to a court or administrative order.  MCH may also disclose medical 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 (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement.

MCH may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, MCH is unable to obtain the person’s agreement;
• About a death MCH believes may be the result of criminal conduct;
• About criminal conduct at MCH; and
• 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.

Coroners, Medical Examiners and Funeral Directors.

MCH may release medical information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  MCH may also release medical information about patients of MCH to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities.

MCH may release medical 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.

MCH may disclose medical 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, MCH may release medical 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 MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information MCH maintains about you:

Right to Inspect and Copy.

You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually, this includes medical and billing records, but may not include some mental health information.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the MCH Health Information Department.  If you request a copy of the information, MCH may charge a fee for the costs of copying, mailing or other supplies associated with your request.

MCH may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by MCH will review your request and the denial.  The person conducting the review will not be the person who denied your request.  MCH will comply with the outcome of the review.

Right to Amend.

If you feel that medical information MCH has about you is incorrect or incomplete, you may ask MCH to amend the information.  You have the right to request an amendment for as long as the information is kept by or for MCH.

To request an amendment, your request must be made in writing and submitted to the MCH Health Information Department.  In addition, you must provide a reason that supports your request.

MCH may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, MCH may deny your request if you ask MCH to amend information that:

• Was not created by MCH, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for MCH;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Even if MCH denies your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, 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 medical record, MCH will attach it to your records and include it whenever MCH makes 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 MCH made of medical information about you other than MCH’s 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 MCH Health Information Department.  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).  The first list you request within a 12-month period will be free.  For additional lists, MCH may charge you for the costs of providing the list. MCH 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 medical information MCH use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the medical information MCH discloses 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 MCH not use or disclose information about a surgery you had.

MCH is not required to agree with your request.  If MCH does agree, MCH 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 MCH Health Information Department.  In your request, you must tell MCH (1) what information you want to limit; (2) whether you want to limit MCH’s 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 MCH communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that MCH only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the MCH Health Information Department.  MCH will not ask you the reason for your request.  MCH 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.  You may ask MCH to give you a 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.

You may obtain a copy of this notice at our website:  www.mchcares.com

To obtain a paper copy of this notice:  MCH Admissions Department

CHANGES TO THIS NOTICE

MCH reserves the right to change this notice.  MCH reserves the right to make the revised or changed notice effective for medical information MCH already has about you as well as any information MCH receives in the future.  Each time you register at or are admitted to MCH for treatment or health care services as an inpatient or outpatient, a copy of the current notice in effect is available upon your request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with MCH or with the Secretary of the Department of Health and Human Services.  To file a complaint with MCH, contact Jim Hoss, Executive Director, Mountains Community Hospital, P. O. Box 70, Lake Arrowhead, CA 92352.  All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to MCH will be made only with your written permission.  If you provide MCH permission to use or disclose medical 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 medical information for the purposes covered by your written authorization, except if MCH has already acted in reliance on your permission.  You understand that MCH is unable to take back any disclosures MCH has already made with your permission, and that MCH is required to retain records of the care that MCH provided to you.