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Effective Date: April 1, 2003 THIS NOTICE DESCRIBES THE TYPE OF INFORMATION MONARCH HEALTHCARE, A MEDICAL GROUP, INC. (MONARCH) GATHERS ABOUT YOU, WITH WHOM THAT INFORMATION MAY BE SHARED AND YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE PLEASE CONTACT OUR PRIVACY OFFICER AT THE ADDRESS LISTED ON THE LAST PAGE OF THIS NOTICE Who Will Follow This Notice This notice describes Monarch’s practices regarding the use of your medical information and that of: >Any Monarch health care professional authorized to enter information into your medical chart if you are hospitalized. Our Pledge Regarding Medical Information: We understand that medical information about you and your health is personal. Protecting medical information about you is important. We create a record of the care and services you receive while in our care. 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 Monarch personnel or your personal doctor. Note, your personal doctor or hospital facility may have different policies or notices regarding the use and disclosure of your medical information created in the doctor’s office or hospital. This patient privacy 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. Monarch is required by law to: • Keep medical information that identifies you private; How Monarch May Use And Disclose Medical Information The following categories describe different ways that Monarch may 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 should fall within one of the categories. >For Treatment. Monarch may use medical information about you to provide you with medical treatment or services. Monarch may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in your care. For example, a doctor treating you for a broken arm may need to know if you have diabetes because diabetes may slow the healing process. Different healthcare professionals within the Monarch network may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. Monarch also may disclose medical information about you to people who may be involved in your medical care after you are discharged from a hospital or that provide services that are part of your care. >For Payment. Monarch may use and disclose medical information about you so that the treatment and services you receive 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 your health plan information about surgery you are scheduled to have at a hospital so that your health plan may determine whether your insurance will cover the treatment. >For Health Care Operations. Monarch may use and disclose medical information about you for healthcare operations. These uses and disclosures are necessary to make sure that all of our members receive quality care. Monarch 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 patients are. >Appointment Reminders. Monarch may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at a facility. >Treatment Alternatives. Monarch may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. >Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. >Individuals Involved in Your Care or Payment for Your Care. Monarch may release medical information about you to a friend or family member who is involved in your medical care. Monarch may also give information to someone who helps pay for your care. >Research. Under certain circumstances, Monarch 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 Monarch would use or disclose medical information for research, the project will have been approved through this research approval process, but Monarch 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, so long as the medical information they review does not leave the hospital. Monarch will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals your identity. >Business Associates. There are some services provided in or for our organization through contacts with business associates. Examples include management services organizations who may provide administrative services to Monarch, transcription services to transcribe dictated reports from the health professionals caring for you in the hospital and copy services for making copies of your health record. When these services are contracted, Monarch may disclose your health information to our business associates so they can perform the services Monarch has authorized them to do. >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. Monarch 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. >Military and Veterans. If you are a member of the armed forces, Monarch may release medical information about you as required by military command authorities. >Workers’ Compensation. Monarch may release medical information about you for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illness. >Health Oversight Activities. Monarch 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 applicable law. >Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, Monarch 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. >Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: >Law Enforcement. Monarch may release medical information if asked to do so by a law enforcement official:
>Coroners, Medical Examiners and Funeral Directors. Monarch may release medical information to a coroner or medical examiner or funeral director. This may be necessary, for example, to identify a deceased person or determine the cause of death or to carry out other duties.
>Protective Services for the President, National Security and Intelligence Activities. Monarch may release 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, or for intelligence, counterintelligence, and other national security activities authorized by law. >Inmates. Monarch may release medical information about inmates of a correctional institution or under the custody of a law enforcement official, to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide the inmate with health care; (2) to protect the inmate’s health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Your Rights Regarding Your Medical Information You have the following rights regarding medical information Monarch maintains about you: >Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes authorization requests, medical and billing records, but may not include some mental health information. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Monarch. 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. Monarch may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. >Right to Amend. If you feel that medical information Monarch has 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 Monarch To request an amendment, your request must be made in writing and submitted to Monarch. In addition, you must provide a reason that supports your request. Monarch 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, Monarch may deny your request if you request to amend information that:
>Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures Monarch made of medical information about you other than Monarch’s own uses for treatment, payment and health care operations, as those functions are described above, or any disclosures that have been specifically authorized by you. To request this list or accounting of disclosures, you must submit your request in writing to Monarch. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. 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 (including research costs and photocopy fees). Monarch 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. >Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information Monarch may 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 Monarch discloses about you to someone who is involved in your care or the payment for your care for example, a family member or friend. We are not required to agree to your request. If Monarch agrees with your request, we will comply with your instructions unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Monarch. 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. >Right to Request Confidential Communications. You have the right to request that Monarch 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 by facsimile or mail. To request confidential communications, you must make your request in writing to Monarch. Monarch will not ask you the reason for your request. Monarch 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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website www.monarchhealthcare.com Changes To This Patient Privacy Notice Monarch reserves the right to change this patient privacy notice. Monarch reserves the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive in the future. Monarch will post a copy of the current notice on our website identified above. The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints If you believe your privacy rights have been violated, you may file a complaint with the Monarch Privacy Officer or with the Secretary of the Department of Health and Human Services. To file a complaint with the Privacy Officer, contact the Monarch Legal Department at (949) 923-3200. All complaints must be submitted in writing. You will not be penalized for filing a compliant. Other Uses of Your Medical Information Other uses and disclosures of your medical information not covered by this notice or the laws that apply to Monarch 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, Monarch will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that Monarch is unable to take back any disclosures that have already made with your permission, and that we are required to retain our records of the care that we provided to you. Privacy Officer: Privacy Officer
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