FOR PROTECTED HEALTH INFORMATION
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.PRINT IF NECESSARY.

During the course of providing services and care to you, Sub-Acute Saratoga Children’s Hospital gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is characterized as your “protected health information.” This Notice of Privacy Practices describes how Sub-Acute Saratoga Children’s Hospital maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.

Sub-Acute Saratoga Children’s Hospital is required by federal and state law to maintain the privacy of your protected health information. Sub-Acute Saratoga Children’s Hospital is also required by law to provide you with this Notice of Privacy Practices that describes Sub-Acute Saratoga Children’s Hospital’s legal duties and privacy practices with respect to your protected health information. Sub-Acute Saratoga Children’s Hospital will abide by the terms of this Notice of Privacy Practices. Sub-Acute Saratoga Children’s Hospital reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that it maintains, including protected health information already in its possession. If Sub-Acute Saratoga Children’s Hospital changes its Notice of Privacy Practices, it will personally deliver or mail a revised notice to you at your current address.

Sub-Acute Saratoga Children’s Hospital will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly permitted or required by law without your authorization. Sub-Acute Saratoga Children’s Hospital has prepared an authorization form for you to use that authorizes Sub-Acute Saratoga Children’s Hospital to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. Sub-Acute Saratoga Children’s Hospital then will not use or disclose your protected health information, except where it has already relied on your authorization.

1. Permissive Disclosures
Sub-Acute Saratoga Children’s Hospital may, in its discretion, use or disclose your protected health without your written authorization in the following circumstances:

a. Your Care and Treatment
Sub-Acute Saratoga Children’s Hospital may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For example, Sub-Acute Saratoga Children’s Hospital may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. Sub-Acute Saratoga Children’s Hospital may also disclose your protected health information to individuals who will be involved in your care if you leave the Sub-Acute Saratoga Children’s Hospital.

b. Billing and Payment
i. Medicare, Medi-Cal and Other Public or Private Health Insurers – Sub-Acute Saratoga Children’s Hospital may use or disclose your protected health information to public or private health insurers (including medical insurance carriers, HMOs, Medicare, and Medi-Cal) in order to bill and receive payment for your treatment and services that you receive at the Sub-Acute Saratoga Children’s Hospital. The information on or accompanying a bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
ii. Health Care Providers – Sub-Acute Saratoga Children’s Hospital may also disclose your protected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed.

c. Health Care Operations
Sub-Acute Saratoga Children’s Hospital may use your protected health information for health care operations. These uses and disclosures are necessary to manage and to monitor our quality of services and care. For example, we may use your protected health information to review our services and to evaluate the performance of our staff in caring for you.

d. Licensing and Accreditation
Sub-Acute Saratoga Children’s Hospital may disclose your protected health information to any government or private agency, such as to the California Department of Health Services and the California Department of Social Services, responsible for licensing or accrediting Sub-Acute Saratoga Children’s Hospital so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.

e. Sub-Acute Saratoga Children’s Hospital’s Special Directory
Sub-Acute Saratoga Children’s Hospital maintains a Special Directory of residents to allow staff to provide certain basic information to members of the clergy who or to other persons who ask for residents by name. Unless you notify Sub-Acute Saratoga Children’s Hospital that you object, it will include certain limited information about you, such as your name, your location in Sub-Acute Saratoga Children’s Hospital, your general condition, and your religious affiliation in its Special Directory.

f. Individuals Involved in Your Care or Payment for Your Care
Unless you specifically object, Sub-Acute Saratoga Children’s Hospital may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person’s involvement with your care or directly relevant to payment related to your care. Sub-Acute Saratoga Children’s Hospital may also disclose your protected health information to these same individuals to assist in notifying them of your location, general condition, or death.

g. Disaster Relief
Sub-Acute Saratoga Children’s Hospital may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.

h. Business Associates
Sub-Acute Saratoga Children’s Hospital may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, quality assurance, legal, or accounting services. Sub-Acute Saratoga Children’s Hospital may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on the Sub-Acute Saratoga Children’s Hospital’s behalf. Sub-Acute Saratoga Children’s Hospital will have a contract with its business associates that obligate the business associates to maintain the confidentiality of your protected health information.

i. Fundraising
Sub-Acute Saratoga Children’s Hospital may use certain protected health information to contact you in an effort to raise money for its operations. Sub-Acute Saratoga Children’s Hospital may disclose the protected health information to business associates or to related foundations that it uses to raise funds for its own benefit. Sub-Acute Saratoga Children’s Hospital will disclose only your name, address, and phone number and the dates you receive health care services. You may notify Sub-Acute Saratoga Children’s Hospital in writing if you object to such disclosures.

j. Research
Sub-Acute Saratoga Children’s Hospital may disclose your protected health information for research purposes, provided that an outside Institutional Review Board overseeing the research approves the disclosure of the information without a written authorization.

k. Hospital Peer Review
Sub-Acute Saratoga Children’s Hospital may disclose your protected health information to hospital medical staffs to aid in the credentialing of applicants and in the peer review of members.

l. Organ Procurement
Sub-Acute Saratoga Children’s Hospital may disclose your protected health information following your death to an organ procurement agency or tissue bank in order to aid in using your organs or tissues in transplantation.

m. Medical Examiner or Funeral Directors
Sub-Acute Saratoga Children’s Hospital may disclose protected health information to a medical examiner or funeral director to allow them to carry out their duties.

n. Appointment Reminders
Sub-Acute Saratoga Children’s Hospital may use or disclose your protected health information to remind you about appointments.

o. Treatment Alternatives or Health-Related Benefits and Services
Sub-Acute Saratoga Children’s Hospital may use or disclose your protected health information to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.

p. Members of Workforce
It is Sub-Acute Saratoga Children’s Hospital’s policy to allow members of its workforce to share residents’ protected health information with one another to the extent necessary to permit them to perform their legitimate functions on Sub-Acute Saratoga Children’s Hospital’s behalf. At the same time, Sub-Acute Saratoga Children’s Hospital will work with and train its workforce members to ensure that there are no unnecessary or extraneous communications that will violate the rights of its residents to have the confidentiality of their protected health information maintained.

q. Veterans
Sub-Acute Saratoga Children’s Hospital may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.

r. Workers’ Compensation
Sub-Acute Saratoga Children’s Hospital may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.

2. Mandatory Disclosures
Sub-Acute Saratoga Children’s Hospital will disclose protected health information to outside persons or entities without your written authorization as required by law in the following circumstances:

a. Court Order; Order of Administrative Tribunal
Sub-Acute Saratoga Children’s Hospital will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency.

b. Subpoena
Sub-Acute Saratoga Children’s Hospital will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.

c. Law Enforcement Agencies
Sub-Acute Saratoga Children’s Hospital will disclose protected health information to law enforcement agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons.

d. Coroner
Sub-Acute Saratoga Children’s Hospital will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to notify next of kin; or to investigate deaths that may involve public health concerns, suspicious circumstances, elder abuse, or organ or tissue donation.

e. Elder Abuse Reporting
Sub-Acute Saratoga Children’s Hospital will disclose protected health information about a resident who is suspected to be the victim of elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain circumstances, Sub-Acute Saratoga Children’s Hospital may disclose further protected health information about the resident to aid the investigating agency in performing its duties. Sub-Acute Saratoga Children’s Hospital will promptly inform the resident about any disclosure unless Sub-Acute Saratoga Children’s Hospital believes that informing the resident would place the resident in danger of serious harm, or would be informing the resident’s personal representative, whom the Provider believes to be responsible for the abuse, and believes that informing such person would not be in the resident’s best interest.

f. National Security and Intelligence Activities, Protected Services for the President and Others
Sub-Acute Saratoga Children’s Hospital will disclose protected health information about a resident to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the President of the United States, certain other persons or foreign heads of states, or to conduct certain special investigations.

g. Other Disclosures Required by Law
Sub-Acute Saratoga Children’s Hospital will disclose protected health information about a resident when otherwise required by law.

1. You have the following rights with respect to your protected health information. To exercise these rights, contact Sub-Acute Saratoga Children’s Hospital at the following address: Sub-Acute Saratoga Children’s Hospital, 13425 Sousa Lane, Saratoga, CA 95070, Attention: Director of Nursing.

a. Right to Request Access
You have the right to inspect and copy your protected health information maintained by Sub-Acute Saratoga Children’s Hospital. In certain limited circumstances, Sub-Acute Saratoga Children’s Hospital may deny your request as permitted by law. However, you may be given an opportunity to have such denial reviewed by an independent licensed health care professional.

b. Right to Request Amendment
You have the right to request an amendment to your protected health information maintained by Sub-Acute Saratoga Children’s Hospital. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an opportunity to submit a written statement disagreeing with the denial.

c. Right to Request Restriction
You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. Sub-Acute Saratoga Children’s Hospital is not required to grant your request, but if it does, it will comply with your request, except in an emergency situation or until the restriction is terminated by you or Sub-Acute Saratoga Children’s Hospital.

d. Right to Request Confidential Communications
You have the right to request that Sub-Acute Saratoga Children’s Hospital communicate protected health information to the recipient by alternative means or at alternative locations.

e. Right to an Accounting
You have the right to receive an accounting of disclosures of your protected health information created and maintained by Sub-Acute Saratoga Children’s Hospital over the six years prior to the date of your request or for a lesser period. Sub-Acute Saratoga Children’s Hospital is not required to provide an accounting of the following disclosures:

• To carry out treatment, payment, and health care operations;
• To respond to your requests for access to protected health information;
• To include your information in the Sub-Acute Saratoga Children’s Hospital’s Special Directory;
• To aid in the identification or care of a resident; or
• To any recipient prior to April 14, 2003 or for protected health information created more than six years before the date of your request for an accounting.

f. Right to Receive a Copy of the Notice of Privacy Practices
You have the right to request and receive a copy of Sub-Acute Saratoga Children’s Hospital’s Notice of Privacy Practices for Protected Health Information in written or electronic form.

If you believe that your privacy rights have been violated, you may file a complaint with Sub-Acute Saratoga Children’s Hospital at the following address 13425 Sousa Lane, Saratoga, CA 95070, Attention: Contact Person. You also have the right to submit a complaint to the Secretary of the U.S. Department of Health and Human Services, 50 United Nations Plaza – Room 322, San Francisco, CA 94102, Attention OCR Regional Manager. Sub-Acute Saratoga Children’s Hospital will not retaliate against you if you file a compliant.

If you have questions about this Notice of Privacy Practices or would like further information about your privacy rights, contact Sub-Acute Saratoga Children’s Hospital at the following address 13425 Sousa Lane, Saratoga, CA 95070, Attention: Director of Nursing.