NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. NO ACTION IS REQUIRED ON YOUR PART.
At Santa Clara County IPA, it has always been our priority to protect the privacy of our health plan members and the confidentiality of their medical information. We know you depend on us to safeguard your personal information and to uphold your privacy rights. This document—which is based on state and federal law, as well as our own company code of ethics—describes our commitment to preserving health plan member confiden-tiality and privacy.
OUR PRIVACY PRACTICES
This notice describes SCCIPA privacy practices for both current and former health plan members. It explains how we use your health information and when we may share your health information with others. It also describes your rights regarding your health information and how you may exercise these rights. We are required by law to maintain the privacy of your health information and to send you a copy of this notice to help you under-stand how the privacy of your health information is maintained at SCCIPA.
SCCIPA maintains physical, electronic and process safeguards that restrict unauthorized access to your health information. Such safeguards include secured office facilities, locked file cabinets and controlled computer network systems and password accounts. You have the right to receive a copy of this notice upon request at any time.
If you would like additional copies of the notice, or have questions relating to the information contained within the notice, please call Member/Customer Services at the toll-free number on your health plan identification card. You may also view a copy of this notice on our Web sites at www.SCCIPA.com. Should any of our privacy practices change, we reserve the right to change the terms of this notice and to make the new notice effective for all health information we maintain. We will provide you with a copy of the revised notice and post the revised notice on our Web sites.
HEALTH CARE INFORMATION MAINTAINED BY SCCIPA
When we refer to "information" or "health information" in this notice, we mean information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health and related health care services. Health information may be transmitted or shared in any form or medium (oral, written, or electronic).
The health information we receive may vary by product; therefore, the examples that follow may not apply to all members, but are designed to represent general categories of information that may be received and maintained by SCCIPA:
• Information provided by you on forms, surveys and our Web sites, such as your name, address and date of birth
• Information from physicians, hospitals or other health care providers, clinics, medical groups or health care service plans
• Information about your transactions and experiences with our affiliates, others, and us, such as products or services purchased, account balances, payment history, claims history, and authorization history
• Information from consumer or medical reporting agencies or other third parties, including medical and demographic information
HOW WE MAY USE OR SHARE YOUR INFORMATION
The following categories describe how we may use and share your health information. For each category, we provide examples that help illustrate each type of use or disclosure. Not every use or disclosure in a category will be listed. However, the ways in which we are permitted to use and share health information will fall into one of these categories.
We may share health information with your doctors or hospitals to help them provide medical care for you. For example, if you are hospitalized, we may allow the hospital staff access to any medical records sent to us by your doctor. We may also use or share your health information with others to help coordinate and manage your health care. For example, we may talk to your doctor to suggest a disease management or wellness pro-gram that can help improve your health.
We may use your health information when paying medical bills for your care submitted to us by you or your health care providers, such as doctors and hospitals. Examples of payment activities include billing, claims management and other related administrative functions.
For Health Care Operations
We may use or share certain health information for necessary health care operations. Examples of health care operations include the following:
• Performing quality assessment and improvement activities
• Evaluating provider and health plan performance
• Conducting or arranging medical reviews to determine medical necessity, level of care or justification of services
• Performing auditing functions
• Resolving internal grievances, such as address-ing problems or complaints about your access to care or satisfaction with services
• Making benefit determinations, administering a benefit plan and providing customer service; and
• Other uses specifically authorized by law
We may also share your health information with other individuals or entities—also known as business associates—that perform payment or health care operations on behalf of SCCIPA. However, we will not share your health informa-tion with these business associates unless they agree in writing to protect the privacy of that information.
To Make Certain Communications to You
We may use or share your health information with a third party acting on behalf of SCCIPA in order to inform you about alternative medical treatments and programs or about health-related products and services that may be of value to you. We may also inform you about enhancements, replacements or substitutions to your health plan coverage.
Information Not Personally Identifiable
We may use or share your health information when it has been "de-identified." Health information is considered to be de-identified when it does not personally identify you.
We may also use a "limited data set" that does not contain any information that can directly identify you. This limited data set may only be used for the purposes of research, public health matters or health care operations. For example, a limited data set may include your city, county and zip code, but not your name or street address.
To the Employee Benefit Plan
We may also share health information related to your enrollment, disenrollment and/or participation in a health plan administered by SCCIPA. We will not share detailed health information with your employer unless they agree to maintain the privacy of your information.
For health plan members residing in California: SCCIPA may not share your health information with your employer unless you provide written permission to SCCIPA.
SPECIAL CIRCUMSTANCES AND STATE AND FEDERAL LAWS
Special situations and certain state and federal laws may require us to use or release your health information. For example, we may be obligated to release your health information for these reasons:
• To comply with state and federal laws that require us to release your health information to others
• To report information to state and federal agencies that regulate our business, such as the U.S. Department of Health and Human Services and your state regulatory agencies
• To assist with public health activities; for example, we may report health information to the Food and Drug Administration for the purpose of investigating or tracking a pres-cription drug or medical device malfunction
• To report information to public health agencies if we believe there is a serious threat to your health and safety or to that of the public or another person; this includes disaster relief efforts
• To report certain activities to health oversight agencies; for example, we may report activities involving audits, inspections, licensure and peer review activities
• To assist court or administrative agencies; for example, we may provide information pursuant to a court order, search warrant or subpoena
• To support law enforcement activities; for example, we may provide health information to law enforcement agents for the purpose of identifying or locating a fugitive, material witness or missing person
• To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official
• To report information to a government authority regarding child abuse, neglect or domestic violence
• To share information with a coroner or medical examiner as authorized by law (we may also share information with funeral directors, as necessary to carry out their duties)
• To use or share information for procurement, banking or transplantation of organs, eyes or tissues
• To report information regarding job-related injuries as required by your state worker compensation laws
• To share information related to specialized government functions, such as military and veteran activities, national security and intelligence activities, and protective services for the President and others
• To researchers when their research has been approved by an institutional review board that has approved the research proposal and estab-lished protocols to ensure the privacy of your health information
• To a family member or friend under any of the following circumstances: (1) if you provide a verbal agreement to allow such a disclosure; (2) if you are given an opportunity to object to such a disclosure and you do not raise an objection; or (3) if it can be inferred from the circumstances, based on SCCIPA professional judgment, that you would not object
WRITTEN PERMISSION TO USE OR SHARE YOUR INFORMATION
For any other activity or purpose not listed above or as otherwise permitted by law we must obtain your written permission—known as an authorization—prior to using or sharing your health information. If you provide a written authorization and you change your mind, you may revoke your authorization in writing at any time.
Once an authorization has been revoked, we will no longer use or share the health information as outlined in the authorization form; however, you should be aware that we may not be able to retract a use or disclosure that was previously made based on a valid authorization.
OTHER RESTRICTIONS REGARDING USE AND DISCLOSURE OF INFORMATION
Depending on the state in which you reside, there may be additional laws related to the use and disclosure of health information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The following are your rights with respect to your health information. If you would like to exercise the following rights, please call Member/Customer Services at the toll-free number on your health plan identification card.
You have the right to ask us to restrict how we use or share your health information for treatment, payment or health care operations. You also have the right to ask us to restrict health information that we have been asked to give to family members or to others who are involved in your health care or payment for care.
Please note that while we will try to honor your requests, we are not required by law to agree to the type of restrictions described above.
You have the right to request confidential communication of health information. For example, if you believe that sending your information to your current mailing address would put your safety at risk (e.g., in situations involving domestic disputes or violence), you may ask us to send the information by alternative means (such as by fax) or to an alternate address. We will accom-modate reasonable requests for confidential communication of your information.
You have the right to inspect and obtain a copy of the health information we maintain about you in a designated record set. A designated record set refers to a group of records that includes enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for SCCIPA.
This right does not obligate us to grant you access to certain types of health information. Please note that under most circumstances we will not provide you with copies of the following information:
• Psychotherapy notes
• Information compiled in reasonable anticipa-tion of, or for use in, a civil or criminal administrative action or proceeding
• Information subject to certain federal laws governing biological products and clinical laboratories
• Medical information compiled and used for quality assurance or peer review purposes
If you request a copy of your designated record set, a fee for the costs of copying, mailing or other associated supplies may be charged. Additionally, under certain circumstances we may deny your request to inspect or obtain a copy of your health information. If we deny your request, we will notify you in writing and may provide you the option to have the denial reviewed. If you would like to request access to review or copy your patient medical records, please directly contact your Primary Care Physician or the health care provider who created the records. Patient medical records include records in any form or medium maintained by, or in the custody or control of, a health care provider relating to health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient.
You have the right to ask us to make changes to health information we maintain about you in your designated record set. These changes are referred to as amendments. We may require that your request be in writing and that you provide a reason for your request.
If we make the amendment, we will notify you that it was made. If we deny your request to amend, we will notify you in writing of the reason for denial. This written notification will explain your right to file a written statement of disagreement. In return, we have a right to rebut your statement. Furthermore, you have the right to request that your initial written request, our written denial and your statement of disagreement be included with your health information for any future disclosures.
You have the right to receive an accounting of certain disclosures of your health information made by us during the six years prior to your request. We may require that your request for an accounting be in writing. Your first accounting is free. Subsequently, you are allowed upon request one free accounting every 12 months. If you request an additional accounting within 12 months of receiving your free accounting, you may be charged a fee. We will inform you in advance of the fee and provide you with an opportunity to withdraw or modify your request.
Please note that, under most circumstances, we are not required to provide you with an accounting of disclosures of the following information:
• Information collected prior to April 14, 2003
• Information shared for treatment, payment or health care operations
• Information already disclosed to you
• Information shared as part of an authorization request
• Information that is incidental to a use or disclosure that is otherwise permitted
• Information provided for use in a facility directory
• Information provided to persons involved in your care or for other notification purposes
• Information shared for national security or intelligence purposes
• Information that was shared or used as part of a limited data set for research, public health or health care operation purposes
• Information disclosed to correctional institu-tions, law enforcement officials or health oversight agencies.
QUESTIONS REGARDING USE AND DISCLOSURE AND YOUR PRIVACY RIGHTS
How to File a Privacy Complaint
If you believe that your privacy rights have been violated in some way, you may file a complaint with Member/ Customer Services at the toll-free number on your health plan identification card during normal business hours. You may also direct your complaints to the Secretary of the U.S. Department of Health and Human Services.
SCCIPA will not penalize you or take any action against you for filing a complaint.
How to Obtain More Information Regarding Your Rights as well as the Use and Disclosure of Your Health Information
If you have any questions about how we use or share your health information or your rights regarding your health information, you may call SCCIPA Provider/Customer Services at 1.800.977.7332 during normal business hours.