Sansum Clinic
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Your Health Information Rights and Choices

Your protected health information as contained in the medical record belongs to you. Hence, you have certain rights and defined choices regarding PHI about you that we store and maintain for you. For example, you can make a choice with regard to what we can disclose when sharing information in a disaster relief situation and also when allowing the Clinic to include information about you in one of our publications. Other choices you can make are as follows:

  • Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information (NPP) promptly upon request. When you sign the General Consent for Treatment form at registration, you are provided a copy of this NPP to read and take home with you. A copy of this same NPP is posted at all Clinic locations and in our website, www.sansumclinic.org. Even if you have obtained this NPP in another form or at another time, you are still entitled to a paper copy of this Notice anytime you request it.
  • Inspect your medical record. You have the right to inspect your PHI as defined in the Designated Record Set (DRS), which is that set of information used to make decisions about your care. DRS includes medical and billing documents but may exclude certain specific provider records, such as mental health information (e.g., psychotherapy notes). To view your medical record in person, you must submit a request in writing to the Sansum Clinic Health Information Services (HIS), Release of Information (ROI) Department, 317 West Pueblo Street, Santa Barbara, CA 93105. You will obtain a response regarding your request within five (5) business days, after which you may come to the ROI Correspondence Office to view your records, both paper and electronic, per your request. In some limited circumstances, your provider may deny your request to inspect your medical record and you would be notified of this denial in writing with an explanation of the basis for the denial within 60 days. In such cases, you may request that your denial be reviewed. Another licensed health care professional chosen by Sansum Clinic will review both your request and the denial. The Clinic will be bound by the outcome of this secondary review.
  • Obtain a copy of your medical record. You may request a copy of your medical record by submitting an Authorization for Use/Disclosure of Protected Health Information form to the Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. There are administrative fees involved in providing you either a paper-based or electronic (i.e. CD, DVD, thumb drive or flash drive) copy for your personal use per your request. However, once a valid release form is on file, there are no charges involved if the copy is to go directly from the ROI Correspondence Office to your physician or other healthcare provider. Your request will be processed in a timely manner according to policy, format, and type of release, and you will be notified as soon as your request is completed. As outlined above, a request to obtain a copy of certain mental health information may be denied by your provider and you will be notified regarding that denial within five (5) business days from receipt of your request.
  • To make an addendum or request an amendment or a correction. If you believe that medical information we have about you is incorrect or incomplete, you may provide us a written addendum to any entry or statement in your medical record or you may ask us to amend the information. To file a written addendum, you must fill out a Request to File an Addendum to Protected Health Information form. To request an amendment, you must complete a Request to Amend Protected Health Information form. The applicable form can be submitted by mail, by fax (805-898-3428), or in person to Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. If your request is not in writing or does not state any reason to support your request, it may be denied. In addition, we may deny your request if you ask us to change information that:
    A. Was not originated by the Clinic, unless the person or entity that generated the information is no longer available to make the amendment.
    B. Is not part of the medical record (your PHI) as defined and kept by the Clinic.
    C. Is not part of the information which you would be permitted to inspect and/or copy under Clinic policy.
    D. Is accurate and complete as is.
    You will receive a response from the ROI Correspondence Office regarding your request within 15 business days following receipt. In the case of any denial, you will be informed in writing regarding the reason(s) for the denial within 60 days.
  • You have the right to revoke your authorization to use or disclose health information at any time except to the extent that the information has already been used or disclosed. For example, Sansum Clinic may obtain your written authorization to use or disclose your health information for purposes other than treatment, payment or health care operations (e.g., you may sign an authorization allowing Sansum Clinic to disclose your protected health information to a life insurance company in order to obtain life insurance coverage). Any authorization you provide to us regarding the use and/or disclosure of your health information may be revoked at any time. You must submit your request in writing to the Sansum Clinic HIS Department (Attention: ROI/ Correspondence Office), 317 West Pueblo Street, Santa Barbara CA 93105. Your request shall be processed within 15 business days following receipt. After you revoke your authorization we will no longer use or disclose your health information for the purposes described in the authorization.
  • To revoke your authorization to use or disclose Protected Health Information at any time except to the extent that the information has already been used or disclosed. For example, Sansum Clinic may obtain your written authorization to use or disclose your PHI for purposes other than treatment, payment or health care operations (e.g. you may sign an authorization allowing the Clinic to disclose your PHI to a life insurance company in order to obtain life insurance coverage). Any authorization you provide to us regarding the use and/or disclosure of your PHI may be revoked at any time. You must submit your request in writing to Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. Your request shall be processed within 15 business days following receipt. After you revoke your authorization, we will no longer use or disclose your health information for the purposes described in the authorization.
  • To obtain an “Accounting of Disclosures” (AOD) of your Protected Health Information. You can ask for a list of events we have shared your PHI over a specified period of six (6) years prior to the date of your request, including to whom your information was disclosed and why. An AOD is a list of certain non-routine disclosures that Sansum Clinic has made involving your PHI for purposes other than treatment, payment or health care operations and for which you have not given authorization, such as disclosures to public health officials. In order to obtain this list, you must complete a Request for an Accounting of Disclosures of Protected Health Information form available at any Sansum Clinic location. You may submit this form by mail, by fax (805- 898 3428), or in person to Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. Your request will be processed within 30 days from receipt. The first list you request within a twelve-month period is free of charge, but Sansum Clinic charges for additional lists within the same twelve-month period.
  • To request a restriction on certain uses and disclosures of your Protected Health Information. You have the right to request a restriction or limitation on the PHI we use or disclose about you. For example, you may restrict or deny disclosure of your PHI to your health plan or insurance company if you paid out-of pocket for the treatment and services received as contained in, or described by, such PHI. We must comply with this type of request. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care, such as family members or friends, as indicated in your medical record. For example, you may ask that we do not use or disclose information about a surgery or treatment that you had at the Clinic to anyone other than your daughter. Sansum Clinic is not required to agree to your request; however, if we do agree, we are bound by our agreement with you except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction of the Clinic’s use or disclosure of your PHI, you must obtain and complete a Request for Special Restriction on Use or Disclosure of Protected Health Information form and submit this form by mail, by fax (805-898-3428), or in person to Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. The request must describe (a) the information you wish restricted; (b) whether you are requesting to limit Sansum Clinic’s use, disclosure or both; and (c) to whom you want the limits to apply. Your request will be processed within 30 days from receipt.
  • To request that Sansum Clinic communicate with you about your health and related issues in a particular manner or at a certain location. For example, you may ask that we contact you at home rather than at work. To request this type of confidential communication, you must obtain and complete a Request for Restriction on the Manner/Method of Confidential Communications form and submit it by mail, by fax (805-898-3428), or in person to Health Information Services, ROI Department, 317 West Pueblo Street, Santa Barbara, CA 93105. Your request should specify the requested method of contact or the location where you wish to be contacted, although you need not give a reason for your request. The Clinic will accommodate all reasonable requests and your request will be processed within 30 days from receipt.
  • To be notified promptly by Sansum Clinic and/or a business associate following a confirmed breach of your PHI. For example, upon discovery that protected health information about you, such as your lab results or x-ray reports, was sent to an unauthorized recipient, we must inform you within required time limits. Furthermore, without unreasonable delay, we must notify certain government agencies as required by law.
  • To choose someone to act for you. If you have given someone medical power of attorney or if someone is your designated legal guardian, that person can exercise your rights in your behalf and make choices about your health information. Sansum Clinic will, however, make sure that your personal representative has such authority and can act for you before we take any action.
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