NOTICE OF PRIVACY PRACTICES

PLEASE REVIEW CAREFULLY

Most patients of Providence Speech and Hearing Center are children. When we refer to “you” or “your” in this Notice, we are refer-ring to the patient. When we refer to types of disclosures of information made to “you,” we mean disclosures made to the patient, the patient’s guardian or person legally authorized to receive information about the patient.

Who Does This Notice Apply To?

Providence Speech and Hearing Center provides health care to our patients and clients through our affiliated hospitals and facilities (“CHOC Children’s Facility”) in partnership with other professionals and organizations. The privacy practices in this Notice will be followed by:

• Each Providence Speech and Hearing Center, including hospitals, clinics, specialty care and primary care practice locations, and all other CHOC Children’s operating units.
• All Providence Speech and Hearing Center employees, staff and other personnel who may need to access your information to perform their job functions.
• Members of the medical staff of each Providence Speech and Hearing Center Facility and other health care professionals who provide health care services at a CHOC Children’s Facility.
• Any member of a volunteer group that is authorized by Providence Speech and Hearing Center to help you.
• Any Business Associate with whom we share health information.

Privacy Is Important to Us:

Providence Speech and Hearing Center is committed to respecting patient privacy and protecting patient health information.

If you do not understand the terms of this Notice, or have any questions, please contact the Privacy Officer at the telephone number listed at the bottom of this Notice.

Examples of Ways We Will Use or Disclose Your Health Information for Treatment, Payment, or Health Care Operations (TPO):

Each time you visit a hospital, physician, or other health care provider, a record of the visit is made. Usually, this record contains symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information, often referred to as a health or medical record, may be used for:
Treatment: The medical information obtained by a nurse, physician, or other members of your health care team will be recorded in your record and used to determine the best course of treatment for you. We will also provide your physician or a subsequent health care provider with copies of reports in order to assist him or her in treating you once you are discharged.
Payment: A bill may be sent to you or your insurance company. The information on or with the bill may include information that identifies you, your diagnosis, procedures, and supplies used to care for you.
Health Care Operations: Members of the medical staff, the risk or quality management staff, and other appropriate members of Providence Speech and Hearing Center may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used and shared to continually improve operations necessary to run each Providence Speech and Hearing Center Facility and to make sure that all patients receive the highest quality care.

Your Privacy Rights

Although your health record is the property of Providence Speech and Hearing Center, you have the right to:

• Request that we restrict how we use and disclose your health information for treatment, payment or health care operations. 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 if you, or someone on your behalf, has paid for the item or service out of pocket in full. To request restrictions, you must make your request in writing. We will inform you of our decision on your written request for restriction.
• You have the right to look at or get copies of your health information in most cases, but the request must be in writing. We must agree to your request or we will send you our reason for denial in writing and explain how you can have the denial reviewed. There may be charges for copies made.
• Request a listing of disclosures of your medical record for the last six years. This list will not include instances where you authorized the release. It will not include releases done during regular hospital treatment, payment and/or health care operations. The request must state the time period desired for the accounting. After the first request there may be a charge.
• Ask in writing that we amend your health information if you believe that your health information is incorrect or important information is missing. We could deny your request to amend a record if the information was not created by us, maintained by us, or if we determine the record is accurate. You may appeal, in writing, a decision by us not to amend a record.
• Request a paper copy of this Notice.
• Request that medical information about you is communicated to you in a confidential manner or at an alternative location, but the request must be reasonable and you must specify how or where you wish to be contacted.

All written requests or appeals as referred to above should be submitted to the Privacy Officer listed at the bottom of this Notice

Our Privacy Responsibilities:

In an effort to provide the highest quality medical care and to comply with certain legal requirements, Providence Speech and Hearing Center will and is required to:

• Maintain the privacy of your health information;
• Provide you with this Notice as to our legal duties and privacy practices with respect to safeguarding your health information;
• Follow the terms of this Notice;
• Notify you if we are unable to agree to meet your requested restrictions; and
• Accommodate reasonable requests you may have to communicate your health information by different means or to different locations.

Examples of How Your Information Will be Used:

• Appointment Reminders and Call Backs: We may use and disclose health information to contact you as a reminder that you have an appointment or to follow-up after a visit.
• Family and Friends: We may give information to those you identify as responsible for payment of your care, a family member, friend or any other person involved in your medical care.

• Patient Information Directory: Unless you notify us otherwise that you object, we will list your name, location in the hospital, general condition and religious affiliation in the hospital patient information directory. This information may be provided to members of the clergy, and except for religious affiliation, to other people who ask for you by name including members of the media. If you would like to opt out of being in the hospital patient information directory, please notify the admission staff of the Providence Speech and Hearing Center location that you are receiving treatment at.

• Health Information Exchange: Providence Speech and Hearing Center may make your individual medical information available to a local, regional, or national Health Information Exchange (HIE) for purposes of treatment, payment or health care operations or as required by law. A HIE is an electronic system that allows participating health care providers to share patient information in compliance with Federal and State privacy laws with the common goal of improving the quality of care for our patients. Unless you notify us otherwise that you object, we may share your health information electronically through the HIE which will allow participating health care providers to access the information as necessary for treatment. Patient health information that currently by law requires an additional signed authorization for release will not be transmitted to the HIE without your consent or as otherwise mandated by law or regulatory requirement. If you would like to opt out of being included in the HIE, please notify the admission staff of the Providence Speech and Hearing Center location that you are receiving treatment at. If you decide to opt out after your visit/admission or have opted out and would like to now opt in, please call the Corporate Compliance Hotline at (877) 388-8588.

• California Immunization Registry: Providence Speech and Hearing Center participates in the California Immunization Registry (CAIR), a secure computer system that stores children’s immunization (shot) records. It is used by health care providers, public health departments, and other programs that serve children to protect the child’s health by allowing access to shot records and sending reminders when shots are due. The registry is private and confidential and can only be used by authorized individuals who serve the child. Unless you notify us otherwise that you object, we will communicate to CAIR that your information may be shared within the registry. If you would like to opt out of information sharing within the registry, please notify the admission staff of the Providence Speech and Hearing Center location that you are receiving treatment at. If you decide to opt out after your visit/admission or have opted out and would like to now opt in, please call the Corporate Compliance Hotline at (877) 388-8588.

We may use or disclose medical information about you without your prior authorization for several reasons.

Subject to certain requirements, we may disclose medical information about you without your prior authorization for the following purposes:

• As required by law: We may disclose health information about you when required to do so by Federal, State, or local law, such as in response to a request from law enforcement in specific circumstances or in response to valid judicial or administrative orders.
• For Public Health: We may disclose health information about you to public health or legal authorities charged with preventing or controlling disease, injury, disability, child abuse or neglect, etc. as required by law.
• Research: We may disclose health information about you to researchers when their research has been authorized through the appropriate Providence Speech and Hearing Center approval process, such as the Institutional Review Board.

The Institutional Review Board reviews research proposals and establishes protocols to ensure the privacy of your health information.

• Health-Related Benefits and Services: We may use health information about you to notify you of healthrelated benefits or services that may be of interest to you. Your information will not be sold or provided to a third-party. You will have the opportunity to refuse or opt-out of receiving this information upon first contact of receiving marketing communications.
• Fundraising: We may use health information about you to solicit funds to benefit Providence Speech and Hearing Center and its foundation. You will have the opportunity to refuse or opt-out of receiving this information upon first contact of receiving fundraising communications.
• Business Associates: There are some services provided at Providence Speech and Hearing Center through contracts with Business Associates (i.e. Providence Speech and Hearing Center may disclose medical information about you to a company who bills insurance companies on Providence Speech and Hearing Center behalf to enable that company to help Providence Speech and Hearing Center obtain payment for the health care services we provide to you). To protect your health information, we require the Business Associate to appropriately safeguard your information.
• Notification: We may use or disclose information about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.
• Funeral Directors, Coroners and Medical Examiners: We may disclose health information to funeral directors, coroners, and medical directors consistent with applicable law to carry out their duties.
• Organ Donation: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities for the purpose of tissue donation and transplant.
• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events.
• Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
• Organized Health Care Arrangement: Each Providence Speech and Hearing Center Facility and its medical staff members have organized and are presenting this document to you as a joint Notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing the past treatment as it may affect treatment at that time.

Other Important Considerations:

Complaints: If you believe your privacy rights have been violated, please contact the Privacy Officer at (877) 388-8588, or by mail at:

Privacy Officer

Providence Speech & Hearing Center

1301 Providence Avenue

Orange, CA 92868

You can also file a complaint with the Secretary of the U.S. Department of Health and Human Services at:

Secretary

U.S. Department of Health and Human Services Office of Civil Rights

200 Independence Avenue, S.W.

Washington DC 20201

Your care will not be affected, negatively or otherwise, for filing a complaint.

Change in Notice: We reserve the right to change this Notice of Privacy Practices at any time and to make the new changes effective for all health information we currently have and any we receive in the future. We will post a copy of the current Notice at each Providence Speech and Hearing Center Facility and on the Providence Speech and Hearing Center web site. The Notice will contain the effective date. In addition, you may request a copy of the current Notice each time you visit a Providence Speech and Hearing Center Facility for treatment or health care services as an inpatient or outpatient.

Other Uses of Health Information: We will not use or disclose your health information without your permission/ authorization, except as described in this Notice. If you choose to authorize disclosure for another purpose, you may revoke such authorization in writing at any time, except to the extent that action has already been taken upon an authorization given to us.

Privacy Officer: (877) 388-8588

This Notice of Privacy Practices is effective as of: November 1, 2016.