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Notice of Privacy Practices

Effective Date: September 2013                                             Review Date:    August 2017

This notice describes how health information about you may be used and disclosed and how you can get access to this information.  Please review carefully.

Our Pledge Regarding Health Information:
We understand that health information about you and your health care is personal. We are committed to protecting your personal health information (PHI). We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Lawndale Christian Health Center (LCHC), whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

  1. make sure that health information that identifies you is kept private;
  2. give you this notice of our legal duties and privacy practices with respect to health information about you; and
  3. follow the terms of the notice that is currently in effect.

All Lawndale Christian Health Center sites including LCHC Eye and Dental clinics, LCHC Pharmacy and LCHC Health Support Services follow the terms of this notice. In addition, these entities, sites, and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice.


  1. Health Care Operations is defined as  business activities that we engage in so as to provide healthcare services to you, including but not limited to, quality assessment and improvement activities, personnel training and evaluation, business planning and development, and other administrative and managerial functions.
  2. Payment means activities that we undertake as a healthcare provider to obtain reimbursement for the provision of healthcare to you which include, but are not limited to: determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and processing health benefit claims.
  3. Protected Health Information or “PHI” means information which identifies you (e.g. name, address, social security number, etc.) and relates to your past, present, or future physical or mental health or condition; the provision of healthcare to you; or the past, present, or future payment for the provision of healthcare to you.
  4. Treatment means the provision, coordination, or management of healthcare and related services on your behalf, including the coordination or management of healthcare with a third party; consultation between LCHC and other healthcare providers relating to your care; or the referral by LCHC of your care to another healthcare provider.


There are a number of Disclosures that do not require your Authorization as outlined below under “How We May Use and Disclose Health Information About You.” Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you

There are three instances where an Authorization is required from you before we disclose your PHI: (1) most Uses and Disclosures of psychotherapy notes; (2) Uses and Disclosures for marketing purposes; and (3) Uses and Disclosures that involve the sale of PHI. We will also get your Authorization before we disclose your PHI regarding most Uses and Disclosures of (1) behavioral health notes and (2) medical information about care for HIV/AIDS.

You may, at your own discretion, provide us with other Authorizations not described in this Notice. It is our Policy only to use and disclose PHI requiring an Authorization consistent with the Authorization as provided by you. Our Compliance Officer will ensure that all Authorizations meet the requirements of the Privacy Rule and that our staff is trained regarding those instances of Uses and Disclosures wherein Authorizations are implicated.

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. 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 the categories.

For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized under our supervision, or at another doctor's office, lab, pharmacy, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietician at the hospital if you have diabetes so that we can arrange for appropriate meals. 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 condition, status and location.

For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment or that you missed an appointment and should contact us to reschedule. Please let us know if you do not wish to have us contact you for this purpose, or if you wish to have us use a different address to contact you for this purpose.

Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this information to you.

Fundraising Activities: We may use health information about you to contact you in an effort to raise money for our not-for-profit operations. We may disclose health information to a business associate so that they may contact you in raising money for our practice. We only will release contact information, such as your name, address, and phone number and the dates you received treatment or services from us. Please let us know if you do not want us to contact you for such fundraising efforts.

Research: Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. The LCHC Quality Assurance Committee of the LCHC Board of Directors must approve all research projects. This committee assures that all projects will be of direct or indirect benefit to our patients and/or community. Their review process also evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. We will obtain your written authorization to use your PHI (Personal Health Information) for research purposes except when our Quality Assurance Committee has determined that:

  1. the use or disclosure involves no more than a minimal risk to your privacy based on the following:
    1. an adequate plan to protect the identifying information from improper use and disclosure;
    2. an adequate plan to destroy the identifying information at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and
    3. adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;
  2. the research could not practically be conducted without the waiver; and
  3. the research could not practically be conducted without access to and use of the PHI.

Before we use or disclose health information for research, the project will have been approved through this research approval process; but we may disclose health information about you to people preparing to conduct a research project. For example, we may help potential researchers look for patients with specific health needs, so long as the health information they review does not leave our facility.

Organ and Tissue Donation: If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.
As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a 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 the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

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

Business Associates: We may use or disclose your PHI to a business associate that performs a business function on our behalf and requires your PHI in order to do so. Such use or disclosure will only occur after performing due diligence to ensure that the business associate is meeting all statutory and contractual requirements. A written contract will be executed with each business associate, and will be reviewed on a yearly basis, to ensure that the business associate is providing adequate PHI safeguards.

Public Health Risks: We may disclose health information about you for public health activities. These activities generally include the following:

  1. to prevent or control disease, injury or disability;
  2. to report births and deaths;
  3. to report child abuse or neglect;
  4. to report reactions to medications or problems with products;
  5. to notify people of recalls of products they may be using;
  6. to notify a person or organization required to receive information on FDA-regulated products;
  7. 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;
  8. 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.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

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 by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release health information if asked to do so by a law enforcement official:

  1. in reporting certain injuries, as required by law – gunshot wounds, burns, injuries to perpetrators of crime;
  2. in response to a court order, subpoena, warrant, summons or similar process;
  3. to identify or locate a suspect, fugitive, material witness, or missing person;
    -Name and address, date of birth or place of birth, social security number, blood type or Rh factor, type of injury, date and time of treatment and/or death, if applicable, and a description of distinguishing physical characteristics.
  4. about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
  5. about a death we believe may be the result of criminal conduct;
  6. about criminal conduct at our facility; and
  7.  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, Health Examiners and Funeral Directors: We may release 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 release health information about patients to funeral directors as necessary to carry out their duties.

Governmental Functions

  • National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
  • Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
  • Military and Veterans: If you are a member of the armed forces or separated or discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

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

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to LCHC’s Director of Medical Records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice, in most cases one of the LCHC Medical Directors will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

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 for as long as we keep the information. To request an amendment, your request must be made in writing on the form “PHI Amendment Request” and submitted to LCHC’s Director of Health Information Management. You must provide on that form the reasons that support your request for an amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  1. was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  2. is not part of the health information kept by or for our practice;
  3. is not part of the information which you would be permitted to inspect and copy; or
  4. is accurate and complete.
  5. Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to LCHC’s Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list; but this date will not be exceed a total of 60 days from the date you made the request.

Right to Request Restrictions: You have a right to request restrictions on how we use and disclose your PHI for treatment, payment and operations, as well as regarding those instances where you have an opportunity to agree or object. We are not required to agree to restrictions for treatment, payment and operations except in limited circumstances. If we do agree to a restriction of any kind then we will honor it going forward, unless you take affirmative steps to revoke it or we believe, in our professional judgment, that an emergency warrants circumventing the restriction in order to provide the appropriate care. In rare circumstances, we reserve the right to terminate a restriction that we have previously agreed to, but only after providing you notice of termination.

You have a right to restrict certain disclosures of PHI to a health plan where you have paid out of pocket in full for the healthcare item or service. You are required to notify all downstream healthcare providers (e.g. a pharmacist) and business associates, including Health Information Exchange(s), of the restriction. We are required by law to honor this restriction and will do so unless affirmatively terminated by you in writing.

To request a restriction, you must make your request in writing to LCHC’s Director of Health Information Management on the “PHI Use and Disclosure Restriction Request”. In your request, you must tell us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.

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 a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.

To request confidential communications, you must make your request in writing to LCHC’s Director of Health Information Management on the “Specified Health Information Confidential Handling Request”. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice:  You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please request it from LCHC’s Privacy Officer. You may also obtain a copy of this notice at our website,


We are required by law to: 1) maintain the privacy of your PHI; 2) provide you with this Notice of our privacy practices; 3) abide by the terns of the Notice currently in effect; and 4) modify this Notice when there are material changes to your rights, our duties, or other practices contained herein. This Notice will remain in effect until it is revised.

We reserve the right to change our privacy practices and the terms of this Notice consistent with applicable law and our current business processes. Should we make revisions to this Notice, we will provide you notification as follows: 1) upon request at any  site including LCHC Eye and Dental clinics, LCHC Pharmacy and LCHC Health Support Services and 2) electronically via our website. Any modifications to our Notice will apply retroactively to your entire PHI, as maintained by us.

In addition to the above, we have an affirmative duty to respond to your requests (i.e. those corresponding to your rights) in a timely and appropriate manner. We support and value your right to privacy and are committed to maintaining reasonable and appropriate safeguards for your PHI. We will not retaliate in any way shape or form should you decided to file a complaint with us or with the Department of Health and Human Services.

Notification of Breach:  You have the right to be notified by LCHC if you are affected by a breach of unsecured PHI. LCHC will conduct a risk assessment of any impermissible uses or disclosures of PHI.  Unless it can be demonstrated that there is a low probability the PHI has been compromised, the use or disclosure will be considered a breach.  Example:  An unauthorized release with a low probability for compromise of PHI would be a fax with PHI that gets sent to the wrong physician, who is notified and promptly destroys the fax with the PHI.  Breach notification would not be necessary in this situation. 

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, complete our “Patient Comment and Privacy Complaint Form”. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, at the top, the effective date. You may request a copy of our most current Notice at any time.

We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign their name and date. This acknowledgement will be filed with your records.

If you have any questions about this notice, please contact Lawndale Christian Health Center’s (LCHC’s) Privacy Officer at (872) 588-3107.

1. AAFP HIPAA Privacy Manual, Revised October, 2002

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