This notice applies to the House Clinic, located in Los Angeles, CA, House Clinic satellite offices (including but not limited to Orange, CA), and House Ear Institute located in Los Angeles, CA (“House Ear”). House Clinic. and House Ear Institute have formed an organized health care arrangement for compliance with federal law regarding the privacy of your health information. If you have any questions about this notice, please contact:
House Clinic. Privacy Officer
2100 West 3rd Street
Los Angeles, CA 90057
House Ear Institute
House Ear Institute Privacy Officer
2100 West 3rd Street
Los Angeles, CA 90057
OUR DUTIES REGARDING YOUR MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice will tell you about the ways in which House Ear may use and disclose medical information about you. We also describe your right and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to:
Make sure that medical information that identifies you is kep private;
Give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of our notice that is currently in effect.
HOW WE MAY USE & DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, researchers or other House Ear personnel who are involved in taking care of you at House Ear. For example, a doctor treating you for dizziness may need to know if you have high blood pressure because it is one of the many causes of dizziness. Or the doctor may need to tell a radiologist that you have an implanted device, so that we can arrange for appropriate MRI examinations. Different departments of House Ear also may share medical information about you in order to coordinate the different services you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside House Ear who may be involved with your medical care, after you leave House ear, such as family members, clergy, or others who use to provide services that are part of your care. Because House Ear Clinic, Inc. and House Ear Institute participate in an organized health care arrangement, they may share your medical treatment information with each other as necessary to carryout medical treatment duties of the organized health care arrangement.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at House Ear may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about physician services you received at House Ear so your health plan will pay us or reimburse you for the physician services. We 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. Because House Ear Clinic, Inc. and House Ear Institute participate in an organized health care arrangement, they may share your medical information with each other as necessary to facilitate payment for duties of the organized health care arrangement.
For Health Care Operations. We may use and disclose medical information about you for House ear operations. These uses and disclosures are necessary to run House Ear and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services House Ear should offer, what services are not need- ed, and whether certain new treatment are effective. We may also disclose information to doctors, nurses, technicians, medical students, researchers and other House Ear personnel for review and learning purposes. We may also, combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvement in the care and servic- es we offer. We 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. Because House Clinic. and House Ear Institute participate in and organized health care arrangement, they may share your medical information with each other as necessary to carry out health care operation duties of the organized health care arrangement.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at House Ear.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommen possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Marketing. We may use and disclose medical information about you when we have face-to-face conversations with you about products or services that may be beneficial to you.
Support Opportunities. House Clinic. may disclose your contact information (name, address, phone numbers) and dates of service to a business associate, an institutionally related foundation, or to the House Ear Institute so that you may be contacted for support opportunities, including financial support, for the House ear organized health care arrangement. House Ear Institute may use your contact information or disclose it to a business associate so that you may be contacted for support opportunities for House Ear Institute or for the House Ear organized health care arrangement. If you do not want House Ear, its business associates or institutionally related foundations, to contact you for support opportunities, please inform us by sending your request to the appropriate contact person(s) listed on the front page of this notice.
Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a friend or — 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.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and disciplinary actions. 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, we may disclose medical information about you in response to a court or administrative order as permitted under California law. We 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 or to obtain an order protecting the information requested as required by California law.
Law Enforcement. we may disclose medical information if asked to do so by a law enforcement official.
— As required by law; In response to a lawful court order, subpoena, warrant, summons, administrative request 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, we are unable to obtain the person’s agreement;
— About a death we believe may be the result of criminal conduct;
— About criminal conduct at House Ear Clinic; 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. We may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause death. We may also disclose medical information about patients of House Ear to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. We may disclose medical information about you to authorized federal officials; for intelligence, counterintelligence, and other national security activities by law.
Protective Services for the President and Others. We 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, we may disclose medical 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.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. 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. If you revoke your permission that was obtained as a condition of obtaining insurance coverage, other law still allows the insurance company to contest a claim under the policy.
YOUR RIGHT REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we 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 we disclose 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 we not use or disclose information about a surgery you had.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writ- ing to the contact person(s) listed on the first page of this notice. A Request for Limitation Form for making your request will be provided upon request. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our 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 we communicate with you about medical matters in a certain way or a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the contact person(s) listed on the first page of this notice. A Request for Confidential Communication
Form for making our request will be provided upon request. We will not ask you the reason for your request. We will accommodate all reasonable requests. Right to Inspect and Copy. You have the right to inspect and copy your medical information maintained by House ear. Usually, this includes medical and billing records, but does not include information compiled in anticipation of a legal proceeding or psychotherapy notes.
To inspect and copy your medical information, you must submit your request in writing to the contact person listed on the first page of this notice. A Request for Access Form for making your request will be provided upon request. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request and will provide you with access and/or copies within 30 days.
We 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 House Ear will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Request Amendment. If you believe that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for House Ear.
To request an amendment, your request must be made in writing and submitted to the contact person(s) listed on the first page of this notice. In addition, you must provide a reason that supports your request. A Request to Amend Form for making your request will be provided upon request.
We 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, we may deny your request if you ask us to amend information that:
— Was not created by us, 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 House Ear Clinic Inc. or House Ear Institute;
— Is not part of the information which you would be permitted to inspect and copy; or
— Is accurate and complete.
If we deny your requested amendment, you may submit a written statement of disagreement, which we will append to your record. we may file a rebuttal statement, which we also will append to your record; if we do, we will provide a copy to you.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this accounting of disclosures, you must submit your request in writing to the contact person(s) listed on the first page of this notice. A Request for Accounting of Disclosures Form for making your request will be provided upon request. 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 lists, we may charge you for the costs of providing the list. We 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 a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us 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 websites, House Clinic, www.houseearclinic.com, or House Ear Institute, www.hei.org.
To obtain a paper copy of this notice, contact person(s) listed on the first page of this notice.
CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at House Clinic. and House Ear Institute. The notice will contain on the first page, in the top center, the effective date. In addition, each time you register at the House Clinic. or House Ear Institute for treatment or health care services as an outpatient, we will make available a copy of the current notice in effect.
COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with House Clinic. or House Ear Institute, as applicable, or with the Secretary of the Department of Health and Human Services. To file a complaint with House Clinic. or House Ear Institute, submit the complaint in writing to the contact person(s) listed on the first page of this notice. All complaints must be submitted in writing. An Individual Complaint Form for making your request will be provided upon request. You will not be penalized for filing a complaint.