Effective Date: May 15, 2006

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

Annex Healthcare Providers Inc. cares about you, our patients/residents/clients, and your privacy. We understand that your health information is personal and we wish to protect that information.

We are required by law to maintain the privacy of your health information; 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 currently in effect.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following lists various ways in which we may use or disclose your health information for purposes of treatment, payment and health care operations.

For Treatment. We will use and disclose your health information in providing you with treatment and services and may disclose information to other providers 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, pharmacists, suppliers of medical equipment, outside laboratory, radiology group or other persons involved in your care. For example, we will contact your physician to discuss your plan of care.

For Payment. We may use and disclose your health information for billing and payment purposes. We may disclose your health information to an insurance or managed care company, Medicare, Medicaid or another third party payor. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for services that will be provided to you.

For Health Care Operations. We may use and disclose your health information as necessary for health-related purposes necessary for Annex Healthcare Providers to function, such as management, personnel evaluation, education and training and to monitor our quality of care.

Federal law allows Annex Healthcare Providers to use and disclose your protected health information for treatment, payment and healthcare operations without your consent. However, because State law continues to require that we obtain your consent for disclosure of PHI for payment purposes, coordination of care with other providers and the disclosure of certain sensitive information protected under State law, we will request your consent for disclosure upon admission.

II. SERVICES INCLUDED IN THIS STATEMENT

This notice applies to Annex Healthcare Providers’ patient care. It applies to our employees, students/trainees and volunteers. It also applies to our medical staff who are part of an organized health care arrangement (OHCA) with Annex Healthcare Providers and will share information for purposes of treatment, payment and health care operations.

III. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following lists various ways in which we may use or disclose your health information.

Facility Directory. Unless you object, we will include certain limited information about you in our home built agency directory. This information includes your name, your location within this agency and your phone number. Our directory does not include specific medical information about you. We may release information from our directory to people who ask for you by name. We may provide the directory information to a member of the clergy.

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

Emergencies. We may use or disclose your health information as necessary in emergency treatment situations.

As Required By Law. We may use or disclose your health information when required by federal, state and/or local law to do so.

Public Health Activities. We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting elder abuse; or neglect or reporting deaths.

Reporting Victims of Abuse or Neglect. If we believe that you have been a victim of abuse or neglect, we may use and disclose your health information to notify a government authority, if authorized by law or if you agree to the report.

Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system.

To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to someone able to help lessen or prevent the threatened harm. This may include disaster relief agencies.

Judicial and Administrative Proceedings. We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a lawfully-issued subpoena, discovery request, or other lawful process.

Law Enforcement. We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiner, as mandated by law, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your health information as required by military command authorities. We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.

Workers’ Compensation. We may use or disclose 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 a law enforcement official or a correctional institution, we may disclose your health information to the institution or official for certain purposes including the health and safety of you and others.

Fundraising Activities. We may use certain limited contact information for fundraising purposes or may provide contact information to a foundation related to the Facility.

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

Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

IV. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

V. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your health information. These rights may be exercised by submitting a request to Annex Healthcare Providers Inc. Each of these rights is subject to certain requirements, limitations and exceptions. At your request, the Agency will supply you with the appropriate form(s) to complete. You have the right to:

Request Restrictions. You have the right to request restrictions on our use or disclosure of your health information for treatment, payment, or health care operations. You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care.

We are required to agree to your requested restriction with respect to release of your health information to any individual outside the Agency unless you are being transferred to another health care institution, the release of records is required by law, third-party payment or to provide you with emergency care.

Access to Personal Health Information. You have the right to request your medical or billing records or other written information that may be used to make decisions about your care. If you request copies of the records, we must provide you with copies. We may charge a fee consistent with State law for our costs in copying and mailing your requested information.

Request Amendment. You have the right to request amendment of your health information maintained by Annex Healthcare Providers Inc. for as long as the information is kept by or for this facility. Your request must be made in writing and must state the reason for the requested amendment.

We may deny your request for amendment if the information (a) was not created by Annex Healthcare Providers Inc., unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for this facility; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by Annex Healthcare Providers Inc.

If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial.

Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your health information. This is a listing of disclosures made by Annex Healthcare Providers or by others on our behalf, but this does not include disclosures for treatment, payment and health care operations or certain other exceptions.

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after April 13, 2003 that is within six years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.

Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice. You may request a copy of this Notice at any time. In addition, you may obtain a copy of this Notice at our website, www.annexhealthcare.com/privacy.htm.

Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.

VI. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION

Under California or federal law, additional restrictions may apply to disclosures of health information that relates to care for psychiatric conditions, substance abuse or HIV-related testing and treatment. This information may not be disclosed without your specific written permission, except as may be specifically required or permitted by Connecticut or federal law. The following are examples of disclosures that may be made without your specific written permission:

  • Psychiatric information. Disclosure may be made of psychiatric information to a mental health program if needed for your diagnosis or treatment. The Agency may also disclose very limited psychiatric information for payment purposes.
  • HIV-related information. Disclosure may be made of HIV-related information for purposes of treatment or payment.
  • Substance abuse treatment. Disclosure may be made of information obtained from a substance abuse program in an emergency.
VII. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact Annex Healthcare Providers’ Privacy Officer. See information listed below.

If you believe that your privacy rights have been violated, you may file a complaint in writing with the Agency or with the Office for Civil Rights in the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint.

To file a complaint with Annex Healthcare Providers Inc., please contact the Privacy Officer. See information listed below.

To file a complaint with the Office for Civil Rights, send a written statement to Office for Civil Rights–Attorney General’s Office
California Department of Justice
Attn: Public Inquiry Unit
P.O. Box 944255
Sacramento, CA 94244-2550

VII. CHANGES TO THIS NOTICE

We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by the Facility as well as for all health information we receive in the future. We will post a copy of the current Notice in the Facility. We will provide a copy of the revised Notice upon request.

PRIVACY OFFICER

To request any of the above rights, or for further information about this Privacy Notice, please contact:

Privacy Officer
Felor Bahadori
16633 Ventura Blvd. Suite #540
Encino, CA 91436

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