Sansum Clinic requests that you sign a General Consent for Treatment form annually or whenever necessary to keep your medical record accurate and up-to-date. This Consent allows the organization, including Sansum Clinic’s Prescription Pharmacy, the Ambulatory Surgery Center, and Cancer Center of Santa Barbara with Sansum Clinic, to use or disclose your health information for purposes relating to treatment, payment or healthcare operations, as follows:
For treatment. We can use your health information and share it with other professionals who are treating you. Information obtained by a nurse, physician, health educator, and other members of your healthcare team will be documented in your medical record and will be used to determine the appropriate course of treatment for your particular medical issues, problems, or concerns, as well as to ensure that there will be continuity when transitions in your care occur. Your record may also contain copies of results from tests performed in the Clinic (e.g. laboratory and radiology studies) and correspondence from other healthcare professionals who have been or are treating you outside the Clinic. We may share your medical information with other physicians or other health care providers who will provide services that we do not provide, or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test for you. Hence, your physician will have an accurate, timely, and complete picture of your medical history and overall health condition when viewing your PHI and will be better able to treat your current medical problems safely.
For payment. We can use and share your health information to bill and get payment from health plans and other payers. Following your treatment, a bill for services rendered is sent to you or to a third party payer (e.g. insurance company, health plan, etc.). The information on the bill may include information that identifies you, as well as your diagnosis, any procedure performed, and medications and supplies used. However, you may request that PHI associated with that portion of your healthcare for which you paid out-of-pocket not be disclosed to your health plan or insurance company.
For our operations. We can use and share your health information to run our practice, improve care, and plan for the future. We may use and disclose information about you to keep Sansum Clinic in operation. Medical staff, the risk manager, quality management, or members of the process and quality improvement team may use information in your medical record to assess the care and outcomes in your case and others like it. This information will then be used to enhance the quality and improve the effectiveness of the healthcare and services we provide all our patients. We may also use and disclose PHI when necessary for medical reviews, attorney services and legal audits, including fraud and abuse detection and compliance programs, as well as business planning and facility management.
For working with our business associates. There are services provided in our organization through agreements with contractors or “business associates.” Examples include billing services that perform invoicing services for us; outside transcription services that transcribe physician dictations; and consultants we may hire to assist us in various aspects of health care administration. When these services are contracted, we may disclose your protected health information to such business associates and subcontractors so that they can perform the job they are contracted to do.
For continuity of care. As indicated earlier, we may share PHI with, or permit access to your PHI to, authorized providers and outside healthcare entities (i.e. covered entities) responsible for your care and treatment. For example, we may allow Cottage Community Health Information Exchange (CCHIE) to have HIPAA-compliant access to your protected health information. CCHIE is a nonprofit electronic information network which enables providers to share information securely in order to better coordinate and enhance medical care. When clinical records are available to the provider at the point of care, the patient receives more accurate and timely service that leads to improved overall patient experience.
For notifications and reminders. We may contact you by postal mail, e-mail (via MyChart), or telephone in order to remind you of an upcoming appointment or to inform you about test results. Sansum Clinic takes privacy and security matters very seriously, and in the event of a privacy violation or security breach involving your PHI, we are also obligated to notify you in accordance with Federal regulations and/or State law.
For communicating with your family and patient representatives. We can use your health information for internal and external communications. Using their best judgment and your authorization, Clinic healthcare professionals may disclose PHI to your family member, patient representative, or any other person you identify as involved in your personal care or bill payment.
For research. We can use or share your information for health research activities. We may disclose information to researchers when an institutional review board (IRB) or privacy board that has reviewed the research proposal and established protocols to ensure the privacy and confidentiality of your health information, has approved the research.
For informing funeral directors, medical examiners, and coroners. We can share health information when a patient expires. We may disclose health information to medical examiners or funeral directors consistent with applicable law in order to assist them in performing duties involving deceased patients.
For marketing. We can use your protected health information for marketing purposes. We may contact you to provide information about treatment alternatives, new medications, or other health-related benefits, programs, and services that may be of interest to you.
For fundraising. We may contact you as part of a fundraising or philanthropic effort. In this situation you have the right to opt out of the specific fundraising or philanthropic solicitation, and you will be provided timely instructions on how to opt out. You can simply tell us not to contact you again. You also have the option of sending your request to be removed from the fundraising mailing list by emailin email@example.com. Moreover, we may not condition treatment on your decision concerning the receipt of fundraising information, and you may opt-in anytime.
For Food and Drug Administration (FDA). We send time-sensitive reports to the FDA. We may disclose to the FDA any health information that relates to unusual or adverse events in connection with medications, supplements, or healthcare equipment in order to facilitate timely medication and/or equipment recalls.
For addressing Workers’ Compensation. We can use and share PHI when reporting on Workers’ Compensation cases. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to disability involving Workers’ Compensation and other similar programs established by law.
For reporting cases pertaining to public health. As required by law, we may disclose your health information to public health officials or legal authorities charged with preventing or controlling disease, injury, or disability, as well as with helping to recall products. Such information may include, but is not limited to, the reporting of abuse or neglect or domestic violence; the reporting of communicable diseases; and the reporting of reactions to medications or problems with products or devices. Additionally, we may share your PHI for preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities. We may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include audits, investigations, inspections, depositions, subpoenas, surveys, licensure and disciplinary actions, criminal procedures or actions, or other activities necessary for the government to monitor programs, compliance with civil rights laws, and the health care system in general.
For law enforcement purposes. We may disclose your health information if requested by law enforcement, military police, homeland security, presidential protective services, or legal authorities. If asked to do so by such law enforcement officials or legal agencies, we may release your PHI in the following circumstances: (a) suspicion of criminal conduct or potential death due to criminal conduct; or (b) in response to a warrant, summons, administrative order, court order, subpoena or other similar legal process.
For compliance with the law. We will share information about you if Federal or State laws require it. This type of disclosure includes sharing your PHI with the Department of Health and Human Services, the California Department of Public Health, and, more specifically, with the Office of Civil Rights as evidence of compliance with HIPAA Privacy Rules.
Effective Date: April 14, 2003
Revision Date: March 29, 2017