Effective Date: April 1, 2003

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

If you have any questions about this notice, please contact, Pomona Valley Hospital Medical Center Compliance/Privacy Officer, 1798 N. Garey Avenue, Pomona, CA 91767, (909) 630-7171.

WHO WILL FOLLOW THIS NOTICE:

This notice describes the privacy practices of Pomona Valley Hospital Medical Center (Hospital) and those of:

• Any health care professional authorized to enter information into your Hospital record, including the Hospital’s medical staff
  
  
• All departments and units of the Hospital
  
  
• Hospital volunteers
  
  
• All employees, staff and other Hospital personnel
  
  
• Our Community Locations: Montclair MRI, Physical Therapy-Montclair, Claremont, Chino Hills and Covina, Robert and Beverly Lewis Family Cancer Care Center and the Breast Health Center
  
  
• Our Affiliated Services: Central Avenue Urgent Care, Family Health Center, Community Health Center, Kids Come First Community Clinic and Chino Hills Primary Care

All these entities, sites and locations will follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment and/or its own limited and Hospital operation purposes described in this notice.

We at the Hospital understand that information about you and your health is personal; therefore, we are committed to protecting health information about you.

We create a record of the care and services that you receive at the Hospital. We use this record to provide you with quality care as well as to comply with legal and other requirements. This record is the property of the Hospital, but the information in the record belongs to you.

This notice applies to records of your care, called protected health information, generated by or at the Hospital, whether made by Hospital personnel or your personal doctor. It includes information that can be used to identify you and that we have created or received about your past, present, or future health or condition, treatment, and payment for healthcare services. This notice explains how, when, and why we use and disclose your protected health information.

A. We Will Use and Disclose Your Information In These Ways.

The following categories will describe different ways that we will use and disclose your protected health information. Not every use or disclosure in a category will be listed. However, all of the ways in which we are permitted to use and disclose information will fall within one of these categories.

1. For treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may also disclose your protected health information to other physicians and providers before or after you have been discharged or transferred to continue your care. For example, if you or members of your family were being transferred to another facility, your records would be transferred with you to that facility to continue patient care. Additionally, we may provide portions of your protected health information to another department in the hospital, such as our physical therapy department, if you are referred for physical therapy treatment.
   
   
2. To obtain payment for treatment. We may use and disclose your protected health information to bill and collect payment for the treatment and services provided to you. For example, we may tell your health plan about the services we gave you so your health plan will pay us or will reimburse you. We may also provide your protected health information to our business associates, such as billing companies, claims processing companies and others that process our health care claims. We may also tell your health plan about treatment you will be receiving to obtain prior approval or to determine whether your plan will cover the treatment.
   
   
3. For health care operations. We may use and disclose your protected health information for Hospital operations. For example, we may use your protected health information to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. As an example, a patient survey may be mailed to your home by an outside agency. We may also provide your protected health information to our accountants, attorneys, consultants, and others to make sure we are complying with the laws that affect us. We may combine your information with that of other patients to decide what services we should offer and to see how we can make improvements. We also may remove information that identifies you and provide the rest of your information to others to study health care and health care delivery. We may provide your information to other providers who have treated you for their limited operational purposes.
   
   
4. For public health activities. We may use and disclose protected health information for public health activities. For example, we will report information about births, deaths, and various diseases to government officials in charge of collecting that information, and we provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death.
   
   
5. For health risks. We may disclose protected health information about you for public health risk reporting. For example, we will report information to:
• Prevent or control disease, injury, or disability
• Report the abuse or neglect of children, elders, and adults
• Report reactions to medications or problems with products
• Notify people of recalls of products that might be in use
• Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
  
  
6. Health oversight activities. We may disclose health 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.
   
   
7. For purposes of organ donation. If you are a potential organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation. We may also release protected health information to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.
   
   
8. For research purposes. In certain limited circumstances, we may provide protected health information to conduct medical research. For example, a research project may involve comparing the health and recovery of all patients with the same condition who received one medication to those who received another.
   
   
9. To avoid harm. To avoid a serious threat to the health or safety of a person or the public, we may provide protected health information to law enforcement personnel or persons able to prevent or lessen such harm. For example, if you are a victim of a crime we may release your protected health information to law enforcement personnel to protect you.
   
   
10. For specific government functions. We may disclose protected health information of military personnel and veterans in certain situations. We may also disclose protected health information for national security purposes, such as providing information to assist in the investigation of terrorist activity.
    
    
11. For workers’ compensation purposes. We may provide protected health information to comply with workers’ compensation laws. For example, we may release current protected health information to the worker's compensation program if you are receiving treatment for a worker’s compensation injury.
    
    
12. Appointment reminders and health related benefits. We may use protected health information to provide appointment reminders or give you information about treatment alternatives or other health care services or benefits we offer.
    
    
13. Fundraising activities. We may use protected health information to raise funds for the Hospital. The money raised through these activities is used to expand and support the health care services and educational programs we provide to the community. We will use or release only contact information, such as your name, address and phone number, and dates of service. If you do not wish to be contacted for fundraising efforts, you must notify our Foundation Department in writing at 1798 N. Garey Avenue, Pomona CA 91767.
    
    
14. Law enforcement. We may release protected health information:
• In response to a court order, subpoena, warrant, summons, administrative request, investigative demand, or similar process
• To report certain types of wounds or injuries
• To identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime under certain limited circumstances
• About a death we believe may be the result of criminal conduct
• About criminal conduct at the Hospital
• In emergencies, to report a crime or the location of a crime or victims or the identity, description, or location of the person who committed the crime.
15. Required by law. We may release protected health information if we are required by law to do so.
    
    
16. Business Associates. We may disclose protected health information to third parties who assist us with some of our duties and functions. These third parties sign contracts promising to protect the privacy of your protected health information.

B. Two Uses and Disclosures Require You to Have the Opportunity to Object.

1. Patient directories. We may include certain limited information about you in the Hospital directory while you are a patient at the Hospital. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.), and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except your religious affiliation, may also be released to people who ask for you by name. This information is released so your family, friends and clergy can visit you in the Hospital and generally know how you are doing.
   
   
2. Disclosures to family, friends, or others. We may provide your protected health information to a family member, friend or other person that you indicate is involved in your care or the payment for your health care or for notification purposes, unless you object in whole or in part.
   

C. All Other Uses and Disclosures Require Your Prior Written Authorization.

In any other situation not described above, we will ask for your written authorization before using or disclosing any of your protected health information. If you choose to sign an authorization to disclose your protected health information, you can later change or take back that authorization in writing to stop any future uses and disclosures (to the extent that we haven't taken any action based on the authorization).

1. You have the right to request limits on uses and disclosures of your protected health information. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make. To request restrictions, you must make your request in writing to Medical Records Department-Correspondence, 1798 N. Garey Avenue, Pomona, CA 91767.
   
   
2. You have the right to choose how we give you your protected health information. You have the right to ask that we give information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). We must agree to your request if we can easily provide it in the format you requested.
   
   
3. You have the right to see and get copies of your protected health information. In most cases, you have the right to look at or get copies of your protected health information for the previous six years. You must make the request in writing by notifying the Medical Records Correspondence desk and filling out a request form. Generally, we will respond to you within 15 working days after receiving your written request. In certain situations, we may not be able to honor your request. If so, we will tell you in writing our reason for the denial and explain any right you may have to request a review. If you request copies of your protected health information a charge may apply. Instead of providing the protected health information you requested, we may provide you with a summary explanation of your protected health information as long as you agree to that and to the cost in advance.
   
   
4. You have the right to request an amendment. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us, in writing, to amend the information. Please contact the Director of Medical Records at 1798 N. Garey Avenue, Pomona, CA 91767. You have the right to request an amendment for as long as the information is retained by the Hospital.
   
   
5. You have a right to get a list of many of the disclosures we have made. This list does not include: disclosures relating to treatment, payment and operations; disclosures provided directly to you; disclosures you previously authorized or disclosures to certain national security and law enforcement agencies. All other disclosures will be included in this list. To request a listing of disclosures, please contact the Medical Records Correspondence Department at Pomona Valley Hospital Medical Center. The listing of disclosures will include all dates of requests beginning April 14, 2003. The first list you request within a 12 month period will be provided free of charge. Any additional lists may involve a fee.
   
   
6. You have a right to get a 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 via e-mail, you are still entitled to a paper copy of this notice. You may obtain a copy of the most recent version of this notice at our website, www.PVHMC.org, all Admitting locations, Patient Relations, all off site entities covered by this notice, outpatient service areas, and the Medical Records Correspondence office.
   
   
7. You have the right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at home or by mail. To request confidential communications, you must make your request at the time of admission or, in writing to the Medical Records Department-Correspondence 1798 N. Garey Avenue, Pomona CA 91767. We will not ask you the reason for your request. We will accommodate your reasonable requests. Your request must specify how or where you wish to be contacted.

CHANGES TO THIS NOTICE:
We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we may receive in the future. The effective date will be noted on the first page in the top right-hand corner of the notice. We will post a copy of the current notice in all the admitting sites throughout the Hospital. In addition, each time you register at or are admitted to the Hospital for treatment or health care services as an inpatient or outpatient, we will make available the current notice in effect. You can get a copy of the current notice at any of the places listed in #6 above.

QUESTIONS AND COMPLAINTS:
If you have any questions about our privacy practices or if you believe your privacy rights may have been violated, you may file a question or complaint with the Hospital in writing to the Patient Relations Department, 1798 N. Garey Avenue, Pomona, CA 91767 or our Compliance/Privacy Officer at 1798 N. Garey Avenue, Pomona, CA 91767. You may also contact the Secretary of the Department of Health and Human Services, or the Office of Civil Rights at (866)OCR-PRIV. You will not be penalized for filing a complaint or for pursuing your rights.