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Your Rights & Responsibilities

Enloe Medical Center of Chico, Calif., is committed to supporting and protecting the fundamental human, civil, constitutional and statutory rights of each individual patient. These rights incorporate the requirements of the Joint Commission on Accreditation of Healthcare Organizations; Title 22; California Code of Regulations, Section 70707; and Medicare Conditions of Participation.

Patient Rights

1. Considerate and respectful care, and to be made comfortable. You have the right to respect for cultural, psychosocial, spiritual, and personal values, beliefs and preferences.

2. Have a family member (or other representative of your choosing) and your own physician notified promptly of your admission to the hospital.

3. Know the name of the physician who has primary responsibility for coordinating your care and the names and professional relationships of other physicians and non-physicians who will see you.

4. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery, and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.

5. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent, or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment, and the risks involved in each, and the name of the person who will carry out the procedure or treatment.

6. Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of physicians, to the extent permitted by law.

7. Be advised, if the hospital/personal physician proposes to engage in or perform human experimentation affecting your care or treatment, you have the right to refuse to participate in such research projects.

8. Reasonable responses to any reasonable requests made for service.

9. Appropriate assessment and management of your pain, information about pain, pain relief measures, and to participate in pain management decisions. You may request or reject the use of any or all modalities to relieve pain, including opiate medication, if you suffer from severe, chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform you that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates.

10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf.

11. Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms.

12. Confidential treatment of all communications and records pertaining to your care and stay in the hospital. You will receive a separate “Notice of Privacy Practices” that explains your privacy rights in detail and how we may use and disclose your protected health information.

13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services, including notifying government agencies of neglect or abuse.

14. Be free from restraints and seclusion of any form, used as a means of coercion, discipline, convenience or retaliation by staff.

15. Reasonable continuity of care, and to know in advance the time and location of appointments, as well as the identity of the persons providing the care.

16. Be informed by the physician, or a delegate of the physician, of continuing health care requirements and options following discharge from the hospital. You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information.

17. Know which hospital rules and policies apply to your conduct while a patient.

18. Designate visitors of your choosing, if you have decision-making capacity, whether or not the visitor is related by blood or marriage, unless:

• No visitors are allowed.

• The facility reasonably determines that the presence of a particular visitor would endanger the health or safety of a patient, a member of the health facility staff, or other visitor to the health facility, or would significantly disrupt the operations of the facility.

• You have told the health facility staff that you no longer want a particular person to visit.

However, a health facility may establish reasonable restrictions upon visitation, including restrictions upon the hours of visitation and number of visitors.

19. Have your wishes considered, if you lack decision-making capacity, for the purposes of determining who may visit. The method of that consideration will be disclosed in the hospital policy on visitation. At a minimum, the hospital shall include any persons living in your household.

20. Examine and receive an explanation of the hospital’s bill regardless of the source of payment.

21. Exercise these rights without regard to sex, race, color, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, educational background, economic status or the source of payment for care.

22. File a grievance. If you want to file a grievance with Enloe Medical Center, you may do so by writing or calling:

Patient Service Excellence Manager
Patient Service Excellence Department
Enloe Medical Center
1531 Esplanade
Chico, CA 95926
Telephone: (530) 332-7005 – This line is accessible 24 hours a day. Your grievance will be reviewed and you will be provided with a written response within 30 days. The written response will contain the name of a person to contact at Enloe Medical Center, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process.

23. File a complaint with the California Department of Public Health and/or The Joint Commission, regardless of whether you use the hospital’s grievance process. The phone numbers and addresses for both agencies are listed below:

California Department of Public Health
Licensing and Certification Program (local office)
126 Mission Ranch Boulevard
Chico, CA 95926
TOLL FREE TELEPHONE NUMBER: 1-800-554-0350

The Joint Commission
Division of Accreditation Operations
Office of Quality Monitoring
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
TOLL FREE TELEPHONE NUMBER: 1-800-994-6610
Fax: (630) 792-5636
E-mail: complaint@jointcommission.org

Patient Responsibilities

Your responsibilities include:

1. Providing complete and accurate information, including your full name, address, home telephone number, date of birth, Social Security number, insurance carrier and employer, when it is required.

2.  Providing, to the best of your knowledge, complete and accurate information about your health and medical history, including present condition, past illnesses, hospital stays, medicines, vitamins, herbal products, and any other matters relating to your health, including perceived safety risks.

3. Ensure that the hospital has a copy of your Advance Directives.

4. Reporting perceived risks in your care and unexpected changes in your condition to your physician.

5. Reporting whether you clearly understand your treatment plan and what is expected of you. You are expected to ask questions when you do not understand information or instructions.

6. Following the treatment plan recommended by your physician. This may include following the instructions of nurses and other health care providers as they carry out the coordinated plan of care, implement your doctor’s orders, and enforce the applicable hospital rules and regulations. If you believe you can’t follow through with your treatment plan, you are responsible for telling your doctor.

7. Your actions and outcomes if you refuse treatment or do not follow your physician’s orders for care and treatment.

8. You are responsible for keeping appointments, and, when you are unable to do so, for notifying your physician or the hospital (for any reason).

9.  Assuring that your health care financial obligations are fulfilled as promptly as possible.

10.  Following hospital rules and regulations affecting patient care and conduct and for assisting in the control of noise and the number of visitors.

11. Being considerate of the rights of others by treating hospital staff, other patients and visitors with courtesy and respect.

12. Being respectful of the property of other persons and the hospital.

13. By leaving valuables at home and only bringing necessary items for your hospital stay.

Patient Complaint / Grievance Process

It is the policy of Enloe Medical Center to provide a systematic approach to resolving conflicts that may arise concerning the care of a patient. Patients and/or designated representatives have the right to communicate complaints regarding the care received, to have those complaints investigated and when possible, resolved. Patient complaints in no way will affect future access to health care. Any patient and/or designated representative who presents a conflict in the care the patient is receiving shall be encouraged to address that issue with the direct patient care provider, the department manager or designee, an administrative representative, or the Patient Service Excellence Department.

  • If the patient/designated representative wishes to file a formal complaint/grievance, he or she may contact Enloe Medical Center's Patient Service Excellence Department at 530-332-7005. This line is accessible 24 hours a day.
  • Complaints may also be filed with the California Department of Health Services' Licensing and Certification Program, 126 Mission Ranch Blvd., Chico, CA 95926 or by calling 1-800-554 0350.
  • Any concerns about patient care and safety in the hospital that the hospital has not addressed may be sent to The Joint Commission by calling 1-800-994-6610 or e-mailing complaint@jointcommission.org.

Advance Directives complaints

Complaints concerning compliance with the advance directive requirements may be filed with the California State Department of Public Health by calling 1-800-554-0350.(For information about creating an advance health care directive, visit our Advance Directive web page.)

Notice of Privacy Practices

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. This "Notice of Privacy Practices" is also available as an Adobe PDF that you can download and print.

If you have any questions about this notice, please contact the Privacy Officer at (530) 332-6759.
Effective September 2013

WHO WILL FOLLOW THIS NOTICE

This notice describes our hospital’s practices and that of:

  • Any health care professional authorized to enter information into your hospital chart.
  • All departments and units of the hospital.
  • Any member of a volunteer group we allow to help you while you are in the hospital.
  • All employees, staff and other hospital personnel.

All Enloe Medical Center entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal. We are
committed to protecting medical information about you. We create a record of the care and
services you receive at the hospital. We need this record to provide you with quality care
and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose medical information
about you. We also describe your rights and certain obligations we have regarding the use
and disclosure of medical information.

We are required by law to:

  • Make sure that medical information that identifies you is kept private (with certain exceptions);
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
  • Follow the terms of the notice that is currently in effect.

How We May Use and 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 the categories.

Disclosure at Your Request

We may disclose information when requested by you. This disclosure at your request may require a written authorization by you.

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, health care students, or other hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as skilled nursing facilities, home health agencies, and
physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.

For Payment

We may use and disclose medical information about you so that the treatment and services
you receive at the hospital may be billed to and payment may be collected from you, an
insurance company or a third party. For example, we may need to give information about surgery
you received at the hospital to your health plan so it will pay us or reimburse you for the surgery.
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. We may also provide basic
information about you and your health plan, insurance company or other source of payment
to practitioners outside the hospital who are involved in your care, to assist them in obtaining
payment for services they provide to you.

For Health Care Operations

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the hospital 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 hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may
also disclose information to doctors, nurses, technicians, medical students, and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we are doing and see where we can make improvements in the care and services 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.

Fundraising Activities

We may use information about you, or disclose such information to a foundation related to the hospital, to contact you in an effort to raise money for the hospital and its operations. You have the right to opt out of receiving fundraising communications. If you receive a fundraising communication, it will tell you how to opt out.

Hospital Directory

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., good, fair, etc.) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t 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.

Marketing and Sale

Most uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of medical information, require your authorization.

To Individuals Involved in Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, we are required to attempt to contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).

For Research

Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the
same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, as long as the medical information they review does not
leave the hospital.

As Required by Law

We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety

We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Special Situations

Organ and Tissue Donation

We may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans

If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation

We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Activities

We may disclose medical information about you for public health activities. These activities generally include the following:

  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report regarding the abuse or neglect of children, elders and dependent adults;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • 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;
  • To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

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, and licensure. 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. 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 (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement

We may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons 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 the hospital; 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 release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary
to carry out their duties.

National Security and Intelligence Activities

We may release medical information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized 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.

Multidisciplinary Personnel Teams

We may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.

Special Categories of Information

In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information — e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information.

To inspect and obtain a copy of medical information that may be used to make decisions about you, you must submit your request in writing to Enloe Medical Center Health Information Management Department Correspondence Office. 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.

We may deny your request to inspect and obtain a 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 the hospital 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 Amend

If you feel 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 the hospital.

To request an amendment, your request must be made in writing and submitted to Enloe Medical Center Health Information Management Department Correspondence Office. In addition, you must provide a reason that supports your 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 the hospital;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

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 other than our own uses for treatment, payment and health care operations (as those functions are described above) and with other exceptions pursuant to the law.

To request this list or accounting of disclosures, you must submit your request in writing to Enloe Medical Center Health Information Management Department Correspondence Office. 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 list (for example, on paper or electronically). The first list you request within a 12-month period will be free.

For additional 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.

In addition, we will notify you as required by law following a breach of your unsecured protected health information.

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, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for purposes of treating you.

If we agree to another special restriction, 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 writing to Enloe Medical Center Health Information Management Department Correspondence Office. 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 at 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 at the time of registration/admissions. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

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.

This is online page can be printed or you can download and print our Adobe PDF file of the "Notice of Privacy Practices."

To obtain a paper copy of this notice contact:
Enloe Medical Center
Health Information Management Department, Correspondence Office
1531 Esplanade, Chico, CA 95926
(530) 332-5518

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 in the hospital. The notice will contain the effective date on the first page. 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 offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer at (530) 332-6759. All complaints must be submitted in writing to the attention of Privacy Officer, Enloe Medical Center, 1531 Esplanade, Chico, CA, 95926.

To file a complaint with the Department of Health and Human Services, mail it to Region IX, Office for Civil Rights, U.S. Department of Health and Human Services, 90 7th Street, Suite 4-100, San Francisco, CA 94103, or phone (415)437-8310.

You will not be penalized for filing a complaint.

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, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have
already acted in reliance on your permission. 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.

Notice of Privacy Practices | Mental Health

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. This "Notice of Privacy Practices | Mental Health" is also available as an Adobe PDF that you can download and print.

If you have any questions about this notice, please contact the Privacy Officer at (530) 332-6759.

Effective November 2013

WHO WILL FOLLOW THIS NOTICE

This notice describes our hospital’s practices and that of:

  • Any health care professional authorized to enter information into your hospital chart.
  • All departments and units of the hospital.
  • Any member of a volunteer group we allow to help you while you are in the hospital.
  • All employees, staff and other hospital personnel.

All Enloe Medical Center entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

Our pledge regarding mental health information

We understand that information about your mental health treatment and related health care
services (mental health information) is personal. We are committed to protecting mental health
information about you. We create a record of the care and services you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to your mental health information generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your mental health information created in the doctor’s office or clinic.

This notice will tell you about the ways in which we may use and disclose mental health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your mental health information.

We are required by law to:

  • Make sure that mental health information that identifies you is kept confidential (with certain exceptions);
  • Give you this notice of our legal duties and privacy practices with respect to mental health information about you; and
  • Follow the terms of the notice that is currently in effect.

How we may use and disclose mental health information about you

The following categories describe different ways that we use and disclose mental health 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 the categories.

Disclosure at Your Request

We may disclose information when requested by you. This disclosure at your request may require a written authorization by you.

For Treatment

We may use mental health information about you to provide you with medical or mental health treatment or services. We may disclose mental health information about you to doctors, nurses, technicians, health care students, or other hospital personnel who are involved in taking care of you at the hospital. For example, a doctor treating you for a mental health condition may need to know what medications you are currently taking, because the medications may affect what other medications may be prescribed for you. In addition, the doctor may need to tell the hospital's food service if you are taking certain medications so that we can arrange for appropriate meals that will not interfere or improperly interact with your medication. Different departments of the hospital also may share mental health information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose mental health information about you to people outside the hospital who may be involved in your
medical or mental health treatment after you leave the hospital, such as skilled nursing facilities, home health agencies, and physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.

For Payment

We may use and disclose mental health information about you so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information about treatment you received at the hospital to your health plan so it will pay us or reimburse you for the treatment. 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.

For Health Care Operations

We may use and disclose mental health information about you for health care operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use mental health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine mental health information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, health care students, and other hospital personnel for review and learning purposes. We may also combine the mental health information we have with mental health information from other hospitals to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of mental health information so others may use it to study health care and health care delivery without learning who the specific patients are.

Fundraising Activities

We may use information about you in order to contact you in an effort to raise money for the hospital and its operations. You have the right to opt out of receiving fundraising communications. If you receive a fundraising communication, it will tell you how to opt out.

Family Members or Others You Designate

Upon request of a family member and with your consent, we may give the family member notification of your diagnosis, prognosis, medications prescribed and their side effects and progress. If a request for information is made by your spouse, parent, child, or sibling and you are unable to authorize the release of this information, we are required to give the requesting person notification of your presence in the hospital, except to the extent prohibited by federal law. Upon your admission, we must make reasonable attempts to notify your next of kin or any other person designated by you, of your admission, unless you request that this information not be provided. Unless you request that this information not be provided we must make reasonable attempts to notify your next of kin or any other person designated by you, of your release, transfer, serious illness, injury, or death only upon request of the family member.

Research

Under certain circumstances, we may use and disclose mental health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of mental health information, trying to balance the research needs with patients’ need for privacy of their mental health information. Before we use or disclose mental health information for research, the project will have been approved through this research approval process, but we may, however, disclose mental health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific mental health needs, as long as the mental health information they review does not leave the hospital.

As Required by Law

We will disclose mental health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety

We may use and disclose mental health information about you when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Special Situations

Organ and Tissue Donation

We may release mental health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Public Health Activities

We may disclose mental health information about you for public health activities. These activities may include, without limitation, the following:

  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report regarding the abuse or neglect of children, elders and dependent adults;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • 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;
  • To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

Health Oversight Activities

We may disclose mental 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.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose mental health information about you in response to a court or administrative order. We may also disclose mental health 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 (which may include written notice to you) or to obtain an order protecting the information requested.

We may disclose mental health information to courts, attorneys and court employees in the course of conservatorship, and certain other judicial or administrative proceedings.

Law Enforcement

We may release mental health information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, certain escapes and certain missing person;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the hospital;
  • When requested by an officer who lodges a warrant with the facility, and
  • When requested at the time of a patient's involuntary hospitalization.

Coroners and Medical Examiners

We may be required by law to report the death of a patient to a coroner or medical examiner.

Protection of Elective Constitutional Officers

We may disclose mental health information about you to government law enforcement agencies as needed for the protection of federal and state elective constitutional officers and their families.

Inmates

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

Advocacy Groups

We may release mental health information to the statewide protection and advocacy organization if it has a patient or patient representative's authorization, or for the purposes of certain investigations. We may release mental health information to the County Patients' Rights Office if it has a patient or patient representative's authorization, or for investigations resulting from reports required by law to be submitted to the Director of Mental Health.

Department of Justice

We may disclose limited information to the California Department of Justice for movement and identification purposes about certain criminal patients, or regarding persons who may not purchase, possess or control a firearm or deadly weapon.

Multidisciplinary Personnel Teams

We may disclose mental health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child, the child’s parents, or an abused elder or dependent adult.

Senate and Assembly Rules Committees

We may disclose your mental health information to the Senate or Assembly Rules Committee for purpose of legislative investigation.

Other Special Categories of Information

Special legal requirements may apply to the use or disclosure of certain categories of information — e.g., tests for the human immunodeficiency virus (HIV) or treatment and services for alcohol and drug abuse. In addition, somewhat different rules may apply to the use and disclosure of medical information related to any general medical (nonmental health) care you receive.

Psychotherapy Notes

Psychotherapy notes means notes recorded (in any medium) 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 and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

We may use or disclose your psychotherapy notes, as required by law, or:

  • For use by the originator of the notes
  • In supervised mental health training programs for students, trainees, or practitioners
  • By the covered entity to defend a legal action or other proceeding brought by the individual
  • To prevent or lessen a serious and imminent threat to the health or safety of a person or the public
  • For the health oversight of the originator of the psychotherapy notes
  • For use or disclosure to coroner or medical examiner to report a patient's death
  • For use or disclosure necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public
  • For the use or disclosure to the Secretary of DHHS in the course of an investigation

Your Rights Regarding Mental Health Information About You

You have the following rights regarding mental health information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and obtain a copy of mental health information that may be used to make decisions about your care. Usually, this includes mental health and billing records, but may not include some mental health information.

To inspect and obtain a copy of mental health information that may be used to make decisions about you, you must submit your request in writing to Enloe Medical Center Health Information Management Department Correspondence Office. 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.

We may deny your request to inspect and obtain a copy in certain very limited circumstances. If you are denied access to mental health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital 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 Amend

If you feel that mental health 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 the hospital.

To request an amendment, your request must be made in writing and submitted to Enloe Medical Center Health Information Management Department Correspondence Office. In addition, you must provide a reason that supports your 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 mental health information kept by or for the hospital;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your mental health record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

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 mental health information about you other than our own uses for treatment, payment and health care operations (as those functions are described above) and with other exceptions pursuant to the law.

To request this list or accounting of disclosures, you must submit your request in writing to Enloe Medical Center Health Information Management Department Correspondence Office. 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 list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional 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.

In addition, we will notify you as required by law following a breach of your unsecured protected health information.

Right to Request Restrictions

You have the right to request a restriction or limitation on the mental health 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 mental health 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 type of therapy you had.

Right to Request Confidential Communications

You have the right to request that we communicate with you about mental health matters in a certain way or at 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 at the time of registration/admissions. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

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.

This is online page can be printed or you can download and print our Adobe PDF file of the "Notice of Privacy Practices | Mental Health."

To obtain a paper copy of this notice contact:

Enloe Medical Center
Health Information Management Department, Correspondence Office
1531 Esplanade, Chico, CA 95926
(530) 332-5518


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 mental health 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 in the hospital. The notice will contain the effective date on the first page. 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 offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with the hospital, contact the Privacy Officer at (530) 332-6759. All complaints must be submitted in writing to the attention of Privacy Officer, Enloe Medical Center, 1531 Esplanade, Chico, CA, 95926.

To file a complaint with the Department of Health and Human Services, mail it to Region IX, Office for Civil Rights, U.S. Department of Health and Human Services, 90 7th Street, Suite 4-100, San Francisco, CA 94103, or phone (415) 437-8310.

You will not be penalized for filing a complaint.

Other Uses of Mental Health Information

Other uses and disclosures of mental health 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 mental health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your mental health information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. 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.