Notice of Privacy Practices 

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

Bridge Home Health and Hospice (“Bridge”) is committed to protecting your privacy. We are legally required to protect the privacy of your health information. We are providing you with our Notice of Privacy Practices (“Notice”) to inform you how medical information about you may be used and disclosed and how you can get access to this information. This document explains your rights and our responsibility to inform you. 

How Bridge May Use and Disclose Your Health Information 

When you become a patient of Bridge, we will use your health information within Bridge and disclose your health information outside of Bridge for the reasons described in this Notice. The following categories describe some of the ways we will use and disclose your health information. 

Treatment. We use your health information to provide you with health care services. We may use your health information to coordinate care within Bridge and with others who are participating in your care. For example, we may share your health information with your Attending Physician to assist in the coordination of your care. We also may disclose your health information to other people outside Bridge who may be involved in your health care, such as hospitals, assisted living or personal care facilities, pharmacies, and family members. 

Payment. We may use and disclose your health information so that the health care you receive can be billed and paid for by you, your insurance company, or another third party. For example, we may provide your medical records to your insurance company so we can get prior payment approval or learn if your plan will pay for the treatment. 

Health Care Operations. We may use your health information and disclose it outside Bridge for our health care operations. These uses and disclosures help us operate Bridge to maintain and improve patient care. For example, we may use your health information to review the care you received and to evaluate the performance of our staff in caring for you. We also may combine health information about many patients to identify new services to offer, what services are not needed, and whether certain therapies are effective. 

Contacting You. We may use and disclose health information to reach you about appointments and other matters. We may contact you by mail, telephone, or email. For example, we may leave voice messages at the telephone number you provide us with, and we may respond to your email address. 

Medical Research. In limited circumstances, clinical researchers may look at your health records as part of your current care, or to prepare or perform research. We will carefully review any research project prior to approval, including for privacy protections. We will not use your health information or disclose it outside Bridge for research reasons without either getting your prior written approval or determining that your privacy is protected. 

Organ and Tissue Donation. We may release health information about organ, tissue, and eye donors and transplant recipients to organizations that manage organ, tissue, and eye donation and transplantation. 

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. 

Public Health Activities. We may disclose health information about you for public health reasons. These activities generally include the following (i) to prevent or control disease, injury or disability; (ii) to report births and deaths; (iii) to report regarding the abuse, neglect, or domestic violence; (iv) to report reactions to medications or problems with products; (v) to notify people of recalls of products they may be using; (vi) 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; (vii) 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 if you agree or when required or authorized by law); and (viii) to notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws. 

Legal Matters. We will disclose health information about you when required to do so by federal, state, or local law, or by the court process. We may disclose health information to a health oversight agency for activities authorized by law, such as for audits, investigations, inspections, and licensure. 

Your Rights Regarding Health Information 

Right to Request Restrictions. You have the right to ask us to restrict the uses or disclosures we make of your health information for treatment, payment, or health care operations, but we do not have to agree. You also may ask us to limit the health information that we use or disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. The request should describe the information you want restricted, say whether you want to limit the use or the disclosure of the information or both, and tell us who should not receive the restricted information. The request must be submitted in writing and be signed and dated. We will tell you if we agree with your request or not. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. However, if you pay out of pocket and in full for a health care item or service, and you ask us to restrict the disclosures we make to a health plan of your health information relating solely to that item or service, we will agree to the extent that the disclosure to the health plan is for the purpose of carrying out payment or health care operations and the disclosure is not required by law. 

Right to Request Confidential Communications. You have the right to request that we communicate with you about your health in a certain way or at a certain location. For example, you can ask that we only contact a designated person or that we only contact you by mail. You need not tell us the reason for your request, and we will not ask. If you request your protected health information to be transmitted directly to another person designated by you, your written request must be signed and clearly identify the designated person and where the copy of health information is to be sent. Your request for confidential communications must be in writing, signed, and dated. 

Right to Inspect and Copy. You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information. If you request a copy of your health information, we may charge a reasonable, cost-based fee that includes only the cost of labor for copying, supplies and postage, if applicable, in accordance with applicable state and federal regulations. If the requested protected health information is maintained electronically and you request an electronic copy, we will provide access in an electronic format you request, if readily producible, or if not, in a readable electronic form and format mutually agreed upon. If we deny access to protected health information, you will receive a timely, written denial in plain language that explains the basis for the denial, your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information. 

Right to Amend. You have the right to request to amend your record must be in writing and must include a reason to support the requested amendment. We will act on your request within sixty (60) days of receipt of the request. We may extend the time for such action by up to 30 days, if we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request. We may deny the request for amendment if the information contained in the record was not created by us, unless you provide a reasonable basis for believing the originator of the information is no longer available to act on the requested amendment; is not part of the designated medical record set; would not be available for inspection under applicable laws and regulations; or the record is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial and an explanation of how to submit that statement. 

Even if we deny your request for amendment, you have the right to submit a written addendum, not to exceed 250 words, with respect to any item or statement in your record you believe is incomplete or incorrect. If you clearly indicate in writing that you want the addendum to be made part of your medical record we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect. 

Right to Accounting. You may request an accounting, which is a listing of the entities or persons (other than yourself) to whom Bridge has disclosed your health information without your written authorization. The accounting would not include disclosures for treatment, payment, health care operations, and certain other disclosures exempted by law. Your request for an accounting of disclosures must be in writing, signed, and dated. It must identify the time period of the disclosures that maintains the records about which you are requesting the accounting. We will not list disclosures made earlier than six (6) years before your request. Your request should indicate the form in which you want the list (for example, on paper or electronically). You must submit your written request. We will respond to you within sixty (60) days. We will give you the first listing within any 12-month period free of charge, but we will charge you for all other accountings requested within the same 12 months. 

Notification of Breach. We will notify you of any breach of your unsecured health information. 

Authorizations for Other Uses and Disclosures 

As described above, we will use your health information and disclose it outside Bridge for treatment, payment, health care operations, and when required or permitted by law. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program. We will not use or disclose your health information for other reasons without your written authorization. For example, most uses and disclosures of psychotherapy notes, uses and disclosures of health information for certain marketing purposes, and disclosures that constitute a sale of health information require your written authorization. These kinds of uses and disclosures of your health information will be made only with your written authorization. You may revoke the authorization in writing at any time, but we cannot take back any uses or disclosures of your health information already made with your authorization. 

Right to a Paper Copy of This Notice 

You have the right to a 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 receive a paper copy. You may obtain a paper copy of this Notice at any of our facilities or by calling the Bridge Privacy Officer at (858) 344-7463. You also can view this Notice on our website at https://www.bridgehh.com. 

Complaints 

If you believe your privacy rights have been violated, you may file a complaint with the Bridge Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. To file a complaint with Bridge contact: 

Bridge Home Health and Hospice 3636 Nobel Drive, Suite 450 San Diego, CA 92122 (858)455-5000 

Attention: Privacy Officer 

Changes to the Terms of this Notice 

We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be posted in our office and on our website at https://www.bridgehh.com. 

Effective Date 

This Notice is effective July 27, 2020 

Acknowledgement of Receipt of Notice of Privacy Practices 

You May Refuse to Sign This Acknowledgement 

I, [full name], have received a copy of the Bridge Notice of Privacy Practices. 

Print Name 

Signature 

Date 

If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following: 

Personal Representative’s name 

Relationship to Patient 

For Program Use Only 

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: 

□ Individual refused to sign 

□ Communications barriers prohibited obtaining the acknowledgement 

□ An emergency situation prevented us from obtaining acknowledgement 

□ Other (Please Specify)