OHS Health and Safety Services,
Inc/Health Tests Direct /Effective Date: April
14, 2003
NOTICE OF PRIVACY
PRACTICES PLEASE REVIEW IT CAREFULLY!
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. We are required to provide you with this
Notice of Privacy Practices and to explain our legal duties under the
federal Health Insurance Portability and Accountability Act ( HIPAA ).
We are required by law to maintain the
privacy of medical information about you. We call this information "protected
health information" or "PHI". We are required to give you notice of our privacy
practices about your protected health information and required to follow the
terms of the notice currently in effect. This Notice of Privacy Practices will tell
you how we may use or disclose information about you. Not all situations will be
described.
In the future we may change the Notice of
Privacy Practices. Any changes will apply to only any
information we receive in the future. A copy of the new notice will be posted at
our HTD website and facility and provided to individuals as required by law.
Ways We Might Use or Disclose PHI
about You without Your Authorization
Appointments and
Other Health Information. We may
send you reminders for medical care or checkups. We may send you information
about health services that may be of interest to you.
As Required By Law
and For Law Enforcement. We will
use and disclose PHI about you when required or permitted by federal or state
law or by a court order.
For Abuse Reports and
Investigations. We are required by
law to report any allegations of child abuse or neglect.
To Avoid Harm.
We may disclose PHI about you to law enforcement in order to avoid a serious
threat to the health and safety of a person or the public.
For Research.
We may use PHI about you for studies and to develop reports. These reports do
not identify specific people.
Other Uses and Disclosures Require Your
Written Authorization
For All Other Situations.
We will ask for your written
authorization before using or disclosing PHI about you. You may cancel this
authorization at any time in writing, or by other appropriate means of
communication if necessary. We cannot take back any uses or disclosures
already made with your authorization.
Other Laws Protect
PHI. Many of our programs have
other laws for the use and disclosure of PHI about you. For example, you must
give your written authorization to us before we can use and disclose chemical dependency
treatment records.
Your PHI Privacy Rights
Right to See and Get
Copies of Your PHI. In most cases,
you have the right to look at or get copies of your PHI. You must make the
request in writing. You may be charged a fee for the cost of copying and
mailing the PHI to you.
Right to Request to
Correct or Update Your PHI. You may
ask us to change or add missing PHI if you think there is a mistake. You must
make the request in writing and provide a reason for your request. However,
there are conditions under which we may deny this request.
Right to Get a List
of Disclosures. You have the right
to ask us for a list of disclosures made after April 14, 2003 and up to six
years prior to the date you made the request. You must make the request in
writing. This list will not include the times that PHI about you was disclosed
for treatment, payment, or health care operations. This list will not include
PHI about you provided directly to you or your family, or PHI that you
authorized.
Right to Request
Limits on Uses or Disclosures of Your PHI.
You have the right to ask us to limit how PHI about you is used or disclosed.
You must make the request in writing and tell us what PHI you want to limit
and to whom you want the limits to apply. We are not required to agree to the
restriction. You can request restrictions be terminated in writing or
verbally.
Right to Revoke
Permission. If you are asked to
sign an authorization to use or disclose PHI about you, you can cancel that
authorization at any time. You must make the request in writing. This will not
affect PHI that has already been shared.
Right To Choose How
We Communicate With You. You have
the right to ask us to share your PHI with you in a certain way or in a
certain place. For example, you may ask us to send PHI about you to your work
address instead of your home address. You must make this request in writing.
You do not have to explain the basis for your request.
Right to File a
Complaint. You have the right to
file a complaint if you do not agree with how we have used or disclosed PHI
about you.
Right to Get a Paper
Copy of this Notice. You have the
right to ask for a paper copy of this notice at any time.
Contact Us to Review, Correct, or Limit
Your PHI, you may want to:
Ask to look at or copy
your PHI.
Ask to limit how PHI
about you is used or disclosed.
Ask to cancel your
authorization.
Ask to correct or change
PHI about you.
Ask for a list of
disclosures of your PHI.
We may deny your request to look at, copy or
change your PHI. If we do deny your request, we will send you a letter that
tells you why your request is being denied, how you can ask for a review of
the denial, and also information about how to file a complaint.
Questions and Complaints:
You may contact us (info below) to file a complaint or to report a problem with
how we have used or disclosed your PHI. Your services will not be affected by
any complaints you make. We cannot retaliate against you for filing a
complaint or refusing to agree to something that you believe to be unlawful. You
may also file a complaint with the California or U.S. Department of Health and
Human Services.
OHS Health and Safety Services, Inc/
Operations Dept. Phone: (949) 764-9301 Fax: (949)
764-9306
1835 Newport Blvd Suite D258, Costa Mesa, CA 92627
Email:
operations@ohsinc.com
Your name SIGNATURE:___________________________________
Your name PRINTED: _____________________________________