Notice of Privacy Practices (HIPAA)

THIS NOTICE TELLS YOU HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

By law we have to keep your health information private. We also have to provide you this detailed Notice of our legal duties and privacy practices relating to your health information and to follow the terms of the Notice that are in effect now. This Notice applies to our use and sharing of your health information in order to enroll you in our program, to see if you are eligible for our program and for payment. This Notice also applies to the use and sharing of your health information so we can provide you with treatment.

PACIFIC PACE MAY USE AND SHARE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS:

For Treatment. We will use and share your health information so we can provide you with care and services and to coordinate your care. We may share information with other caregivers involved in your care. Your health information may be used by doctors involved in your care and by nurses and home health aides as well as by physical therapists, social workers, personal care attendants or other persons involved in your care. For example, members of the health care team (which includes your primary care doctor, nurses, social workers, physical and occupational therapists, and other care givers) will talk about your plan of care and talk to any specialists about care given to you.

For Payment. We may use and share your health information for billing and payment purposes. We may share your health information with a person who represents you, or with an insurance or managed care company, Medicare, Medicaid, or the state agency in charge of Pacific PACE. For example, we may share health information with Medicare or the state agency in order to see if you continue to be eligible for Pacific PACE services. We will also require you to sign a release so that Pacific PACE can share personal information with Medicare, Medicaid, and the state agency for these reasons as a rule of your enrollment agreement.

For Health Care Operations. We may use and share your health information as needed for health care operations, such as management, staff evaluation, training and to check quality of care. For example, we will use facts about your treatment in order to check the quality of care. We may share your health information with another person or company with which you have or had a relationship if that person or company asks for your information for its health care operations or to find health care fraud and abuse or to see if you receive good health care.

We will ask you to sign a release giving your okay for Pacific PACE to use and share your personal information for treatment, payment and health care operations.

THE FOLLOWING IS A LIST OF OTHER WAYS PACIFIC PACE CAN USE OR SHARE YOUR HEALTH INFORMATION, INCLUDING TIMES WHEN WE CAN DO SO ONLY AFTER GIVING YOU A CHANCE TO AGREE OR SAY NO, AND SOMETIMES WITHOUT YOUR AUTHORIZATION (OR GIVING YOU A CHANCE TO AGREE OR SAY NO) AT ALL.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may share health information about you with a family member, close personal friend or other person you tell us to, including clergy, who is helping with your care.

Emergencies. We may use or share your health information, as needed in emergency treatment situations.

As Required By Law. We may use or share your health information when the law tells us to do so.

Business Associates. Our business associates are people and companies that do services on our behalf and use health information. We may share your health information with a person or company who has signed a contract with business associate or us who needs the information to do services for the Pacific PACE. Our business associates promise to keep this health information private.

To Create and Aggregate De-Identified Data. We may use your health information to create information that is not individually identifiable health information. We also may disclose your health information to one or more of our business associates in order to create information that is not individually identifiable health information, regardless of whether we plan to use the created information. However, in order to do this, we will first need to “de-identify” your health information. See HIPAA De-Identified PHI vs. PHI Limited Data Set Form. In order to help protect your privacy and reduce the risk of re- identification, personnel conducting de-identification activities will be separated from those personnel conducting aggregation activities. Further, your health information will be de-identified before it is aggregated and all methods of re-identification (including methods held by business associates) will be secret and never disclosed to anyone, unless you tell us in writing that it’s okay to do so.

Public Health Activities. We may share your health information for public health reasons. These reasons may include, for example, telling a public health agency in order to prevent or control disease, injury or disability; telling about elderly abuse or neglect or telling about deaths.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we think that you have been a victim of abuse, neglect or domestic violence, we may use and share your health information to tell a government agency, if allowed by law or if you agree to the report.

Health Oversight Activities. We may share your health information with an agency that watches over the health care system. As a rule of enrollment, we will ask you to sign a release that says it is okay to share your personal information with Medicare, Medicaid, and the state agency in charge of Pacific PACE for these purposes.

To Avert a Serious Threat to Health or Safety. When needed to stop a serious threat to your health or safety or the health or safety of the public or another person, we may use or share health information. We will give only the amount of information needed to someone who can help lessen or prevent the serious threat.

Judicial and Administrative Proceedings. We may share your health information if a court or legal order tells us to. We also may share information if a subpoena, discovery request, or other lawful process tells us to. We will try to contact you about the request or to get an order or have the person promise to keep the information private.

Law Enforcement. We may share your health information for certain law enforcement reasons, including, for example, to obey the reporting rules; to obey a court order, warrant, or similar legal process; or to answer certain requests for information about crimes.

Research. We may use or share your health information for research reasons if we look at and give the okay to how the information will be kept private, if the researcher is getting the information when preparing a research plan, if the research happens after your death, or if you agree to the use or sharing of your information.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may share your health information with a coroner, medical examiner, funeral director or, if you are an organ donor, with a company that helps with the donation of organs and tissue.

Disaster Relief. We may share health information about you to a disaster relief company.

Military, Veterans and other Specific Government Functions. If you are in the armed forces, we may use and share your health information if we are asked to by the military. We may share health information for national security purposes or as needed to protect the President of the United States or certain other officials or to do certain special investigations.

Workers’ Compensation. We may use or share your health information to comply with laws relating to workers’ compensation or similar programs.

Inmates/Law Enforcement Custody. If you are under the custody of law enforcement officials or a correctional institution, we may share your health information with the institution or officially for certain purpose including the health and safety of you and others.

Fundraising Activities. We may use certain limited information to contact you in an effort to raise money for Pacific PACE, provided that any fundraising communication explains clearly your right to opt out of future fundraising communications. We are required to honor your request to opt out.

Appointment Reminders. We may use or share health information to remind you about appointments.

Treatment Alternatives and Health-Related Benefits and Services. We may use or share your health information to tell you about different treatments and health-related benefits and services that may be of interest to you.

IF PACIFIC PACE USES OR SHARES YOUR HEALTH INFORMATION IN OTHER WAYS, WE NEED YOUR WRITTEN AUTHORIZATION

Except as said in this Notice, we will ask for your written okay to use and share your health information. This written okay is called an Authorization. You may take away your okay in writing at any time. If you take away your okay, we will no longer use or share your health information for the reasons written down, except if we have already used the information in the way you told us we could.

OUR RESPONSIBILITIES TO YOU

We are required by law to maintain the privacy of your protected health information (including electronically stored protected health information), to provide you with notice of our legal duties and privacy practices with respect to your protected health information (including electronically stored protected health information), and to notify you following a breach of any unsecured protected health information (including any unsecured electronically stored protected health information).

We are legally obligated to abide by the terms of this Notice of Privacy Practices currently in effect. In order for us to apply a change in a privacy practice (as described in this Notice of Privacy Practices) to any protected health information that we created or received prior to issuing a revised Notice of Privacy Practices, we need to give you notice and reserve the right to do so. Specifically, we reserve the right to change the terms of this Notice of Privacy Practices and to make the new Notice of Privacy Practices effective for all protected health information (including electronically stored protected health information) that we maintain. Any revised Notice of Privacy Practices will be transmitted to you in paper form.

YOUR RIGHTS TO HEALTH INFORMATION PRIVACY

Listed below are your rights that have to do with your health information. Each of these rights has rules, limits and exceptions. In order to use these rights, you may have to ask Pacific PACE in writing. When you ask Pacific PACE, we will give you the right form to fill out.

You have the right to:

Request Restrictions. Restrictions mean limits. You have the right to ask for limits on how Pacific PACE uses or shares your health information for treatment, payment, or health care operations. This includes:

  • The right to give Pacific PACE a written consent that limits the information shared and limits the persons we can give the information to.
  • The right to request limits on the health information we share about you with a family member, friend or other person who helps with your care or the payment for your care.

We do not have to agree to the limits that you ask for on how we use your health information within Pacific PACE. We will limit sharing your information outside of Pacific PACE (except to the Federal Agency and the State Agency that watch over Pacific PACE) to match with your written consent. We will agree to the limits you asked for on how to use your health information within Pacific PACE if the limits are reasonable and if we can do them. With respect to a disclosure to a health plan, we will agree to your request if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the PHI pertains solely to a health care item or service for which you, or other person other than the health plan on your behalf, has paid us in full. If we do agree to the limits you asked for, we will obey what you ask except if needed to give you emergency treatment.

Access to Personal Health Information. You have the right to look at and get a copy of your medical or billing records or other written information that may be used to make decisions about your care, with some exceptions. You must ask in writing. We will respond to your request within 30 days, subject to 45 C.F.R. § 164.524(b)(2)(ii). In most cases we may charge a fee to copy and mail what you have asked for.

Request Amendment. Amendment means change. You have the right to ask for a change of your health information that Pacific PACE has for as long as the information is kept by or for Pacific PACE. You must ask in writing and must say the reason for the change you are asking for.

We may not agree to the change you ask for if the information (a) was not made by Pacific PACE , unless the person who first made the information is no longer able to make the change that you are asking for; (b) is not part of the health information held by or for Pacific PACE; (c) is not part of the information to which you have a right of access; or (d) is already right and complete, as thought by the Pacific PACE.

If we do not agree to what you asked for, we will tell you why in writing. We will also tell you that you have the right to say to us in writing that you do not agree with us.

Request an Accounting of Disclosures. You have the right to ask for a list of the people or companies that Pacific PACE has given your health information to. This list may also include people or companies that others have given your information to on behalf of Pacific PACE. There are some limits to what needs to be on this list. The list does not include those we have given your information to for treatment, payment and health care operations, or because you have signed an Authorization, and certain other reasons.

If you want this list, you must ask us in writing, giving us a time-period starting after July 1, 2019 that is within seven years from the date of your asking. The first time you ask for a list within a 12-month period we will not charge a fee; if you ask again within a 12- month period, we may charge you our costs.

Request a Paper Copy of This Notice. You have the right to get a paper copy of this Notice, even if you said that you wanted to get it on a computer. You can ask for a copy of this Notice at any time.

Request Confidential Communications. You have the right to ask us to talk with you or write to you about your health matters in a certain way. We will agree to your requests if it is reasonable.

SPECIAL RULES REGARDING SHARING OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION

Laws in California may give more rules to keep information about mental health and drug or alcohol abuse treatment and HIV private. Pacific PACE will obey any California laws that may give additional rules for keeping information about mental health and drug and alcohol abuse treatment and HIV private.

This Notice of Privacy Practices is effective July 1, 2019.

REQUESTS

To request to see and/or receive a copy of your records or request corrections to your information, you must submit a request in writing to:

Pacific PACE
Attn: Medical Records
50 Alessandro Place, Suite A20
Pasadena, CA 91105

To request restrictions on use or disclosure of your information, request accounting of disclosures of your information, or request confidential communications, you must submit a request in writing to:

Pacific PACE
Attn: Quality Improvement Coordinator
50 Alessandro Place, Suite A20
Pasadena, CA 91105

FOR MORE INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like more information about your privacy rights, please contact the Pacific PACE Quality Improvement Coordinator at (800)-851-0966 (TTY/TDD 800-735-2922).

If you think that your privacy rights have not been followed, you may make a complaint by calling the Pacific PACE Quality Improvement Coordinator, by faxing your written form to (626) 360-2489 or writing to:

Pacific PACE
Attention: Quality Improvement Coordinator
50 Alessandro Place, Suite A20
Pasadena, CA 91105

Or

Privacy Officer
California Department of Health Care Services P.O. Box 997413
MS 0010
Sacramento, CA 95899-7413
(916) 445-4646 (Voice)
(877) 735-2929 (TTY/TDD)

Or

Secretary of the U.S. Department of Health and Human Services Office of Civil Rights
Attention: Regional Manager
50 United Nations Plaza, Room 322
San Francisco, California 94102 (800)-368-1019

CHANGES TO THIS NOTICE

We have the right to change this Notice and to make the changed or new Notice rules apply for all health information already received and held by the Pacific PACE as well as for all health information we get in the future. We will provide a copy of the changed Notice if you ask for it.

© 2019 Pacific PACE. All rights reserved.

H0934_PacificWeb_CMSApproved_05/21/2019

Page last updated 4/15/2019

© 2019 Pacific PACE. All rights reserved.

H0934_PacificWeb_CMSApproved_05/21/2019

Page last updated 4/15/2019