Effective: June 16, 2004
Notificación Sobre las Prácticas de Privacidad en Español

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please call the Privacy Officer at (520)874-3606.

Who Will Follow This Notice: This Notice describes the privacy practices of University Physicians Hospital and Clinics, a division of University Physicians Healthcare (UPH).

Our Pledge Regarding Your Health Information:
We understand that information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive at our facilities. We need these records to provide you with complete and comprehensive care and to comply with certain legal requirements. This Notice applies to all of the records your care generates at our various sites and locations. This Notice tells you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding use and disclosure of health information. We are required by law to make sure that health information that identifies you is kept private, give you this Notice of our legal duties and privacy practices with respect to health information about you, and follow the terms of this Notice currently in effect.

How May We Use And Disclose Health Information About You
The following categories describe different ways we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.

Treatment. We may use health information about you to provide you with health treatment or services. We may disclose health information about you to doctors, physician's assistants, nurses, technicians, students, emergency services and health transportation providers, health equipment providers and/or others involved in your care. For example, different departments within our organization may share health information about you in order to coordinate elements of your care, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside of our organization such as referring physicians and home health care nurses in connection with your health care treatment.

Payment. We may use and disclose health information about you to your insurance, or other parties who help pay for your care. For example, we may tell your insurance provider about a treatment you are going to receive to determine whether your plan will pay for that treatment.

Heath Care Operations. We may use and disclose health information about you for our operations. These uses and disclosures are necessary to run our organization and to make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, students and other health care personnel for teaching purposes.

Business Associates. There may be some activities provided for our organization through contracts with outside businesses. Examples include transcription services and collection agencies. Under such contracts, we may disclose your health information to these businesses to perform the job we have asked them to do. These contracts also require the businesses to protect the health information we disclose to them.

Appointment Reminders. We may contact you to remind you about your appointment for health care.

Treatment Alternatives. We may use and disclose health information to tell you about possible treatment options or alternatives that may be of interest to you and other health-related benefits and services.

Hospital Directory. We may include certain limited information about you in the hospital directory while you are an inpatient at the hospital. This information may include your name, location in the hospital, your general condition (fair, stable, etc.) and your religious affiliation. The directory information, except for your religious information, may also be disclosed to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, even if they don't ask for you by name. We provide this service so your family, friends and clergy can visit you in the hospital and generally know how you are doing. If you are admitted to the hospital and choose not to be included in the hospital directory, you must complete a Facilities Directories Exclusion Form. You may complete this form at the time of your admission in the Registration area of the hospital or you may request that the nursing staff provide you with this form on the unit. If you choose to have your name removed from the hospital directory, the hospital will not be able to inform family, friends or clergy of your location in the hospital and you may not be able to receive flowers, visitors, cards or other correspondence during your hospital stay.

Individuals Involved In Your Care. Unless you object, we may disclose health information about you to a friend or family member who is involved in your health care. We may also disclose health information about you to an entity assisting in a disaster-relief effort so that your family can be notified about your location and condition. If you are not present or able to object, then we may, using our professional judgment, determine whether the disclosure is in your best interest.

Research. As an academic health center, we may use and disclose health information about you for research purposes. We will only use and disclose your information for a research project if we obtain your permission, or if the need to obtain your permission has been waived by a designated review committee that meets federal requirements.

As Required by Law. We will disclose health information about you when required to do so by federal, state or local law.

To Avert Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. Disclosure would only be to persons who could help prevent the threat.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU - SPECIAL SITUATIONS

Organ and Tissue Donation. We may disclose health information to organizations that handle and monitor organ donation and transplantation.

Military. If you are a member of the armed forces, we may disclose health information about you as required by military command authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may disclose health information about you for workers' compensation or similar programs to the extent necessary to comply with laws relating to workers' compensation or other similar programs established by law. These programs provide benefits for work-related injuries or illness.

Public Heath Risks. As required by law, we may disclose health information about you for public health activities. For example, we may undertake these activities:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure subject to certain requirements when mandated or authorized by law.

Health Oversight Activities and Registries. We may disclose health information to a health oversight agency for activities authorized by law and to patient registries for conditions such as tumor, trauma and burn. These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor the health care system, the outbreak of disease, government programs and compliance with civil rights laws, and to improve patient outcomes.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request or other lawful process.

Law Enforcement. We may disclose health information if asked to do so by a law enforcement official: for the reporting of certain types of wounds in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness or missing person; about the victim of a crime, if under certain limited circumstances, we are unable to obtain the person's agreement; about a death we believe may be the result of criminal conduct; about suspected criminal conduct on the premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose health information about patients of the hospital to funeral directors as necessary to carry out their duties.

National Security. We may disclose health information about you to authorized federal officials for purposes of national security.

Inmates. An inmate does not have the right to this Notice.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right To Access, Inspect and Copy. You have the right to access, inspect and have copied health information used to make decisions about your care. Usually, this includes health and billing records, but does not include some records such as psychotherapy notes. Requests to access your health information should be sent to the University Physicians Healthcare contact person and address listed in this Notice. You may be charged a fee for that service. Under very limited circumstances, your request may be denied, such as a request for psychotherapy notes. You may request that a denial be reviewed by contacting the University Physicians Healthcare contact person listed in this Notice.

Right To Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment of your record for as long as the information is kept by or for our organization. To request an amendment to your record, your request must be made in writing on the authorized form we will provide to you upon request and submitted to the University Physicians Healthcare contact person listed in this Notice. In addition, you must provide a reason that supports your request. We may deny your request for an amendment to your record if it is not in writing or does not include a reason to support the request. We also may deny your request if you ask us to amend information that was not created by us, unless you provide UPH with a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment; is not part of the record; would not be available for inspection; or the record is accurate and complete.

Right to an Accounting of Disclosures. You have the right to receive a list of the disclosures of your health information that may be made by us for a period of six years prior to the date of the request, except that we are not required to tell you of disclosures made before April 14, 2003. This list will not include disclosures made for treatment, payment, health care operations purposes, or disclosures made at your request. If you request more than one list of disclosures in a 12-month period, we may charge you a fee. To request this list for "accounting of disclosures," you must submit your request in writing on the authorized form we will provide to you upon request. Contact the Health Information Management Department located on the first floor of UPH Hospital at Kino Campus, or speak with the staff at the UPH clinic location where you receive services for guidance.

Right To Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or in the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing on a form that will be provided to you upon 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. This request should be sent to the University Physicians Healthcare contact person listed on this Notice.

Right To Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at certain locations. You must make your request in writing on a form that will be provided to you upon request. We will accommodate all reasonable requests. This request should be sent to the University Physicians Healthcare contact person listed on this Notice.

Right To Paper Copy of This Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may download a copy of our current Notice from University Physicians Healthcare Hospital and Clinics at Kino Campus website at www.uph.org.

UPH Contact Person: UPH Privacy Officer at (520) 874-3606.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this Notice or by other laws that apply to us will be made only with your written authorization. If you provide authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. We are unable to retract any disclosures we have already made with your authorization, and we are required to retain records of the care that we provided to you.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the Privacy Officer at (520) 874-3606. You will not be penalized for filing a complaint.

REVISIONS TO THIS NOTICE
We may revise this Notice to reflect any changes in our privacy practices. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as for any information we receive in the future. We will post a copy of the current Notice in the locations where you receive services. The effective date of this Notice is found at the top of this document.