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NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and disclosed, and how you can gain access to your individually identifiable health information.

 A.  OUR COMMITMENT TO YOUR PRIVACY:

SilvaCare  (the Practice or We), is dedicated to maintaining the privacy of your personally identifiable, protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We strive to maintain the confidentiality of health information that identifies you. This notice explains the privacy practices that we maintain concerning your PHI. 

The terms of this notice apply to all records containing your PHI that are created or retained by the Practice.  We reserve the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment to this notice will affect all of your records that our Practice has created or maintained in the past and any records of yours that we may create or maintain in the future. You may request a copy of our most current notice at any time.

 B.  IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

SilvaCare
Attn: Privacy Officer
2284 North State College Boulevard
Fullerton, California 92831

 C.  WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

The following categories describe the different ways in which we may use and disclose your PHI, unless you object:

  1. Treatment.  Our Practice may use your PHI in the course of your treatment. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Our staff may use or disclose your PHI to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as other healthcare providers, your spouse, your children, or your parents.
  2. Payment.  Our Practice may use and disclose your PHI to bill and collect payment for the services and products you may receive from us. We do not participate or bill insurance, so we do not disclose your information for the purpose of being reimbursed by insurance. However, we may use and disclose your PHI to obtain payment from those who may be responsible for such costs, such as family members.
  3. Health Care Operations. The Practice may use and disclose your PHI to operate our business. For example, we may use and disclose your information for our operations. Our Practice may use your PHI to evaluate the quality of care you received from us, to develop protocols and clinical guidelines, to develop training programs, or to aid in credentialing and medical review.
  4. Appointment Reminders. The Practice may use and disclose your PHI to contact you and remind you of an appointment.
  5. Release of Information to Family/Friends. The Practice may release your PHI when necessary, to a friend or family member involved in your care. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
  6. Disclosures Required by Law. The Practice will use and disclose your PHI when we are required to do so by federal, state, or local law or regulation.

  D.  USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES:

 The following categories describe unique scenarios in which we may use or disclose your PHI:

When required by law to collect information for the purpose of:

  1. Health Oversight Activities. The Practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions and other activities necessary for the government to monitor its programs, compliance with civil rights laws, and the health care system in general.
  2.  Lawsuits and Similar Proceedings. The Practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process, by another party involved in the dispute. But we shall only disclose PHI after we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
  3. Law Enforcement. We may release PHI if required to do so by a law enforcement official:
    • regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
    • concerning a death we believe has resulted from criminal conduct;
    • regarding criminal conduct at our offices;
    • in response to a warrant, summons, court order, subpoena, or similar legal process;
    • to identify or locate a suspect, material witness, fugitive or missing person;
    • in an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator).

4.  Deceased Patients. The Practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information to funeral directors as necessary to perform their jobs.

5.  Organ and Tissue Donation. If you are an organ donor, the Practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation.

6.  Serious Threats to Health or Safety. The Practice may use and disclose your PHI when necessary, to reduce or prevent a serious threat to your health and safety or that of another individual or the public. But we will only make such disclosures to a person or organization able to help prevent the threat.

7.   Military. The Practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

8.  Workers’ Compensation. The Practice may release your PHI if required for workers’ compensation and similar programs.

 E. YOUR RIGHTS REGARDING YOUR PHI:

 The health and billing records we maintain are the physical property of Practice.   The information in it, however, belongs to you. You have a right to: 

  1. Confidential Communications. You have the right to request that our Practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. To request a specific type of confidential communication, you must make a written request to the Privacy Officer, identifying the requested method of contact, or location where you wish to be contacted. Our Practice will accommodate reasonable requests.  You do not need to give a reason for your request. 
  1. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. To request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion:
  • the information you wish restricted;
  • whether you are requesting to limit our Practice’s use, disclosure, or both; and
  • to whom you want the limits to apply.
  1. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you and your care, including your billing and medical records, but not your psychotherapy notes. In order to inspect and/or obtain a copy of your PHI, You must submit your request in writing to the Privacy Officer. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.  We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. The review shall be conducted by different licensed health care professional of our choosing.
  1. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. Our Practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion:
    1. accurate and complete;
    2. not part of the PHI kept by or for the Practice;
    3. not part of the PHI which you would be permitted to inspect and copy; or
    4. not created by our Practice, unless the individual or entity that created is not available to amend the information.
  1. Paper Copy of this Notice. You may receive a paper copy of our notice of privacy practices anytime, upon request by contacting the Privacy Officer.
  1. Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our Practice. To file a complaint, contact our privacy officer at the address provided above. All complaints must be submitted in writing, and you will not be penalized for filing a complaint.
  1. Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.  Please note, we are required to retain records of your care.

Again, if you have questions regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above.

Acknowledgement

 I hereby acknowledge that I have received and read this Notice of Privacy. I understand that I may request additional copies of this notice at any time.