Effective Date: This Notice is effective on January 31, 2016.

I. Who Presents this Notice

This joint notice (“Notice”) describes how your medical information will be used and disclosed by Chapman Global Medical Center (“CGMC ”), members of its workforce, medical staff members, and allied health professionals who practice at this facility.

CGMC and the individual health care providers who provide services at the Hospital are together sometimes referred to collectively as “we” or “us” in this Notice. While CGMC and health professionals engage in many joint activities and provide services in a clinically integrated care setting, the Hospital and health professionals are separate legal entities and separately responsible for complying with this Notice and applicable law. This Notice applies to services furnished to you at CGMC as a Hospital inpatient or outpatient or any other services provided to you in a Hospital-affiliated program involving the use or disclosure of your medical information (known as “protected health information” or “PHI”). Your doctors and other health care providers may have different practices or notices about the use and disclosure of your PHI in their own offices or clinics.

II. Privacy Obligations

We understand that your PHI is private and personal, and we are committed to protecting it. We are required by law to maintain the privacy of your PHI and to provide you with this Notice of legal duties and privacy practices. When we use or disclose your PHI, 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

CGMC collects health information about you and stores it in a chart in an electronic health record. This information constitutes your medical record. The medical record is the property of CGMC, but the information in the medical record belongs to you. HIPAA Privacy regulations allows for the use and disclosure of your health information without your written authorization for the following purposes:

A. Treatment, Payment and Health Care Operations. Your PHI may be shared among the Hospital, their Hospital-affiliated programs, and by your health care providers, as necessary, for treatment, payment, or for health care operations.

• Treatment. Your PHI may be used and disclosed to provide treatment and other services to you. For example, your PHI may be used to diagnose and treat your injury or illness or it may be disclosed to other providers involved in your treatment.
• Payment. Your PHI may be used and disclosed to obtain payment for services provided to you. For example, your PHI may be used to obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care, or to verify health care coverage. Your medical information could be disclosed to providers who may be involved with your medical care after you leave the hospital such as home health agencies or skilled nursing facilities.
• Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. For example, PHI may be used to evaluate the quality and competence of physicians, nurses, and other health care workers. We may use and disclose your PHI as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs, and business planning and management.
B. You. PHI may be disclosed to you or your designee to permit you to inspect and/ or obtain a copy of your PHI in a designated record set in accordance with 45 C.F.R.
§ 164.524, to provide you with an accounting of disclosures of your PHI in accordance with 45 C.F.R. §164.528, or to notify you of a breach of security with respect to your PHI.

C. Secretary. Your PHI may be disclosed to the Secretary of the U.S. Department of Health and Human Services (“Secretary”) when required to investigate or determine our compliance with the law.

D. Minors. If you are a minor, your PHI may be disclosed to a parent, guardian, or other person acting in loco parentis when such person has authority to act on your behalf with respect to your health care unless, such disclosure is prohibited by law, or, in the opinion of the professional person who is treating or counseling you, the involvement would be inappropriate.

E. Personal Representatives. If you are an adult or an emancipated minor, we may disclose your PHI to a person who, under applicable law, has authority to act on your behalf in making decisions related to your health care.

F. Facility Directories. Unless you object, we may include limited information about you in a facility directory, including your name, location in the Hospital(s), general health condition (e.g. good, fair, etc.), and religious affiliation, without obtaining your authorization. However, your name will not be listed if you are located in a specific ward, wing or unit the identification of which would reveal that you are receiving treatment for (1) mental health and developmental disabilities; (2) alcohol and drug abuse; (3) HIV/AIDS; (4) communicable disease(s); (5) genetic testing; (6) child abuse and neglect; (7) domestic and elder abuse; or (8) sexual assault. Information in the directory may be disclosed to anyone who asks for you by name or members of the clergy; provided, however, that religious affiliation will only be disclosed to members of the clergy.

G. Relatives, Close Friends and Other Caregivers. Your PHI may be disclosed 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 (1) your agreement is obtained; (2) you do not object to the disclosure after being provided an opportunity to object; or (3) it can be reasonably inferred 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 professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative, or a close personal friend, we will disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family may be notified about your condition, status, and location.
H. Public Health Activities. Your PHI may be disclosed 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; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and (6) to report to a school, as required by law, to provide proof of immunization of a student or prospective student when you agree, or if you are a minor, your parent or guardian agrees, to the disclosure.

I. Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, when required by law, with your agreement, or when authorized by law to report abuse, neglect, or domestic violence if there is a reasonable belief that the disclosure is necessary to prevent serious harm to you or other potential victims, or if a law enforcement or other public official determines an immediate law enforcement activity depends upon the disclosure and would be materially and adversely affected by waiting until you can agree.

J. Health Oversight Activities. Your PHI may be disclosed to a health oversight agency for oversight activities authorized by law, including: audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of the health care system or government benefit or regulatory programs for which PHI is relevant to determine eligibility and compliance.

K. Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to an order of a court or administrative tribunal or in response to a subpoena, discovery request, or other lawful process.

L. Law Enforcement Officials. Your PHI may be disclosed 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.

M. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical or mental health information about you to the correctional institution or law enforcement official. This disclosure 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. Additionally, disclosure may be made when required, as necessary to the administration of justice.

N. Decedents. Your PHI may be disclosed to a family member, or other persons who were involved in your care or payment for health care prior to your death when the PHI is relevant to such person’s involvement, unless doing so is inconsistent with your prior expressed preference known to us.

O. Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. Your PHI may be disclosed to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to your death.

P. Organ and Tissue Donation. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking, or transplantation.

Q. Research. Your PHI may be disclosed without your consent or authorization if an Institutional Review Board/Privacy Board approves a waiver of authorization for disclosure.

R. Health or Safety. Your PHI may be disclosed when permitted by law to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety or is necessary for law enforcement to identify and apprehend a criminal. We will comply with California law in reporting your PHI for public health activities or health oversight activities. If you disclose information related to child abuse or other types of actual or threatened abuse, such information may be reported to governmental authorities responsible to investigate such abuse. If you commit a crime on the premises, your PHI may be used to report the crime.

S. Military, Veterans, National Security, and Other Government Functions. Your PHI may be disclosed to units of the government with special functions, such as the U.S. military or the U.S. Department of State, under certain circumstances.

T. Workers’ Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.

U. Fundraising Purposes. Your PHI may be used or disclosed for fundraising purposes; however, you have the right to opt out of receiving such fundraising communications. If you receive a fundraising communication, it will tell you how to opt out.

V. Business Associates. There are some services provided by us through contracts with business associates, including transcribing your medical record, surveying for patient satisfaction, obtaining payment, or making copies of your medical record. When these services are provided by contracted business associates, we may disclose the appropriate portions of your PHI to our business associates so they can perform the job we have asked them to do.

W. Privacy Breaches. We will notify you in writing if we discover a breach of your unsecured health information, unless we determine, based on a risk assessment, that notification is not required by applicable law. You will be notified without unreasonable delay and no later than 5 business days after discovery of the breach. Such notification will include information about what happened and what has been done or can be done to mitigate any harm to you as a result of such breach.

X. As Required by Law. Your PHI may be disclosed when required to do so by any other law not already referred to in the preceding categories.

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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, your PHI may be used or disclosed only when you provide your written authorization. For instance, you will need to provide a written authorization before PHI may be sent to your life insurance company or to the attorney representing the other party in litigation in which you are involved.

B. Marketing. Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. However, marketing materials can be provided to you 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, appointment reminders, case management or care coordination, or alternative treatments, therapies, providers, or care settings without Your Marketing Authorization.

C. Sale of PHI. Except for disclosures pursuant to your prior authorization or prior permission or approval for research as described in 45 C.F.R. §164.532, we must obtain your written authorization for any sale of your PHI.

D. Psychotherapy Notes. Psychotherapy notes are notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Your written authorization must be obtained prior to any use or disclosure of psychotherapy notes, except as follows: (1) when required or permitted by law by the originator of the notes for treatment; (2) for certain training programs in mental health;
(3) by CGMC or a Hospital to defend itself in a legal action or other proceeding brought by you; (4) use or disclosure that is required by law; (5) disclosure to you pursuant to your right of access to your PHI or an accounting of disclosures of your PHI; (6) to the Secretary to determine our regulatory compliance; (7) for health oversight activities; (8) to coroners or medical directors, as necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public; or (9) to apprehend a criminal.

E. Highly Confidential Information. In addition, federal and California law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that is: (1) maintained in psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, treatment, and referral; (4) about HIV/AIDS testing, diagnosis or treatment; (5) about communicable disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic and elder abuse; or (9) about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.

V. Your Rights Regarding Your Protected Health Information

A. Right to Request Additional Restrictions. You may request restrictions on the 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 all requests for additional restrictions will be carefully considered, we are not required to agree to a requested restriction. However, we must comply with any request by you to restrict the disclosure of PHI to a health plan if (a) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, or (b) the disclosure is related solely to a health care item or service for which you, or a person on your behalf, have paid in full. If you wish to request additional restrictions, please obtain a request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office.

B. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

C. Right to Revoke Your Authorization. You may revoke your authorization, Your Marketing Authorization or any written authorization obtained in connection with your PHI, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Hospital Privacy Office. If you desire to revoke an authorization, please obtain a revocation form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office.

D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. 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 (i.e. abortion or mental health treatment); or the health care provider determines, in good faith, that access to the patient records requested by the representative would have a detrimental effect on the provider’s professional relationship with the minor patient or on the minor’s physical safety or psychological well-being. If you desire access to your records, please obtain a record request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. If you request copies of paper records you will be charged the reasonable cost of copies in accordance with federal and state law. You also will be charged for the postage costs, if you request that the copies be mailed to you.

E. Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. Your request will be accommodated unless we determine that the information that would be amended is accurate and complete or other special circumstances apply.

F. Right to Receive an Accounting of Disclosures. Upon your 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 (6) years and does not apply to disclosures that occurred prior to April 14, 2003. If you desire to obtain an accounting of disclosures, please obtain a request form from the Hospital Privacy Office and submit the completed form to the Hospital Privacy Office. If you request an accounting more than once during a twelve (12) month period, you will be charged $0.25 per page of the accounting statement.

G. 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.

H. For Further Information or to Report a Problem. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated, or disagree with a decision made about access to your PHI, you may contact the Privacy Office at the Hospital where you were treated. You may also file a written complaint with the Secretary of the US Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Hospital Privacy Office or the Secretary. The address for the Office for Civil Rights (OCR) is as follows: Region IX – San Francisco (American Samoa, Arizona, California, Guam, Hawaii, Nevada) Michael Leoz, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103. Voice Phone (800) 368-1019, FAX (415) 437-8329, TDD (800) 537-7697.

VI. Changes to this Notice

The terms of this Notice may be changed at any time. If this Notice is changed, the new Notice terms may be made effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If this Notice is changed, the new notice will be posted in waiting areas around the Hospital and on the Hospital’s website. You also may obtain any new notice by contacting the Hospital Privacy Officer.

VII. Privacy Office

You may contact our Privacy Officer at CGMC. The address for the Hospital Privacy Officer is listed below:

Chapman Global Medical Center Attn: Privacy Officer
2601 E. Chapman Ave., Orange, CA 92869
Telephone Number: (714)-953-3539