Tahoe Forest Hospital District Joint 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.

Original effective date: April 14, 2003
Revision effective date: July 2, 2025

Tahoe Forest Hospital District (“TFHD”) is a clinically integrated care setting in which patients typically receive health care from more than one health care provider. This means that your care may be provided by (1) Hospital staff members, (2) physicians and other practitioners in Hospital-based practices and Clinics, and/or (3) physicians and other practitioners who practice in independent settings but who have privileges to provide care at the Hospital. Your personal doctors and other practitioners who are independent may have different policies and notices regarding the use and disclosure of your medical information created in the doctor’s office or clinic. TFHD accepts no legal responsibility for activities solely attributable to these other legally separate independent providers or care settings. However, these independent practitioners have agreed to abide by the practices described in this notice through an Organized Health Care Arrangement (OHCA), with respect to care they provide to you here at the Hospital and the medical information in your records here at the Hospital.

Therefore, this notice describes our Hospital’s privacy practices and those of: (1) any health care professional authorized to enter information into your Hospital chart; (2) all departments and units of the Hospital; (3) any member of a volunteer group we allow to help you while you are in the Hospital; (4) all employees, Hospital-based physician practices, staff and other Hospital personnel; and (5) all owned subsidiary entities of the Hospital including the entities described below.

All these entities, practitioners and caregivers follow the terms of this notice. In addition, these entities, practitioners and caregivers may share medical information with each other for treatment, payment, or health care operations purposes described in this notice.

This notice describes the TFHD privacy practices and that of:

• Any health care professional authorized to enter information into your TFHD chart.
• All departments and units of TFHD.
• Any member of a volunteer group we allow to help you while you are in the TFHD.
• All employees, staff and other TFHD personnel.
• The Tahoe Forest Hospital District includes Tahoe Forest Hospital, Incline Village Community Hospital, Tahoe Forest MultiSpecialty Clinics, Tahoe Forest Long Term Care Center, Gene Upshaw Memorial Tahoe Forest Cancer Center, Tahoe Forest Home Health, Tahoe Forest Hospice, Tahoe Forest Health Clinic & Tahoe WoRx – Occupational Health and Wellness, Tahoe Center for Health and Sports Performance, Tahoe Forest Physical Therapy Services, Tahoe Forest Health System Retail Pharmacy, Tahoe Forest Health System Sleep Disorder Center, Tahoe Forest Retail Pharmacy, Tahoe Institute for Rural Health Research, Tahoe Forest Hospital Auxiliary, The North Lake Tahoe Community Health Care Auxiliary, Tahoe Forest Health System Foundation, and Incline Village Community Hospital Foundation.

All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes described in this notice.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. Each time you visit Tahoe Forest Hospital District, we create a record of the care and services you receive. 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 the Hospital District, whether made by Hospital District personnel or your personal doctor.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private (with certain exceptions);
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

Disclosure at Your Request

We may disclose information when requested by you. This disclosure at your request may require a written authorization by you.

For Treatment

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, pharmacist, health care students, or other Hospital District personnel who are involved in taking care of you within the Hospital District. Different departments of the Hospital may share medical information about you to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the Hospital who may be involved in your medical care after you leave the Hospital, such as skilled nursing facilities, home health agencies, and physicians or other practitioners. For example, we may give your physician access to your health information to assist your physician in treating you.

For Payment

We may use and disclose health information about you so the treatment and services you receive within our Hospital District may be billed to and payment may be collected from you, an insurance company or a third party. 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. We may also provide basic information about you and your health plan, insurance company or other source of payment to practitioners outside the Hospital who are involved in your care, to assist them in obtaining payment for services they provide to you.

For Health Care Operations

We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the Hospital District and make sure that all our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Hospital District patients to decide what additional services the Hospital District should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Hospital District personnel for review and learning purposes. We may also combine the medical information we have with medical information from other Hospital Districts to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. There are some services provided through contracts with Business Associates (e.g. TFHD may disclose medical information about you to a company who bills insurance companies on TFHD’ behalf to enable that company to help TFHD obtain payment for the health care services we provide to you). To protect your health information we require the business associate to appropriately safeguard your information.

Health Information Exchange

We may make your protected health information available electronically through an information exchange service to other health care providers, health plans and health care clearinghouses that request your information. Participation in information exchange services also lets us see their information about you.

Appointment Reminders

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care within the Hospital District.

Marketing and Sales

Most uses and disclosures of medical information for marketing purposes, and disclosures that constitute a sale of medical information, require your authorization.

Fundraising Activities

We may use information about you, or disclose such information to a foundation related to the Hospital, to contact you in an effort to raise money for the Hospital and its operations. You have the right to opt out of receiving fundraising communications. If you receive a fundraising communication, it will tell you how to opt out. If you do not want us to contact you for fundraising efforts, you must notify the Tahoe Forest Hospital District Foundation by calling (530) 582-6277, the Incline Village Community Hospital Foundation by calling (775) 888-4204, or emailing [email protected].

Hospital Directory

We may include certain limited information about you in the Hospital directory while you are a patient at the Hospital. This information may include your name, location in the Hospital, your general condition (e.g., fair, stable, etc) and your religious affiliation. Unless there is a specific written request from you to the contrary, this directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This information is released so your family, friends and clergy can visit you in the Hospital and generally know how you are doing.

To Individuals Involved in Your Care or Payment for Your Care

We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are in the Hospital. In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you arrive at the emergency department either unconscious or otherwise unable to communicate, we are required to attempt to contact someone we believe can make health care decisions for you (e.g., a family member or agent under a health care power of attorney).

Research

Disclosure of health information for the purposes of research shall only be made after documented approval for the research. Names of the individual will not be included unless there is a specific authorization.

To Avert a Serious Threat to Health or Safety

We may use and disclose medical 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.

Organ and Tissue Donation

We may release medical 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.

Military and Veterans

If you are a member of the armed forces, we may release medical information about you as required by military command authorities. Workers’

Compensation

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

Public Health Risks

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

• To prevent or control disease, injury or disability
• To report births and deaths
• To report the abuse or neglect of children, elders and dependent adults
• 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 if you agree or when required or authorized by law;
• To notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply with state and federal laws.

Health Oversight Activities

We may disclose medical 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 medical information about you in response to a court or administrative order. We may also disclose medical 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 (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement

We may release medical information if asked to do so by a law enforcement official:

• 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;
• 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 release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the Hospital to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities

We may release medical 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 medical 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.

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This disclosure 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.

Incidental Disclosures

Certain incidental disclosures of your medical information may occur as a byproduct of lawful or permitted use and disclosure of your medical information. For example, a visitor may inadvertently overhear a discussion about your care occurring at a nurse’s station. These incidental disclosures are permitted if the Hospital applies reasonable safeguards to minimize the disclosure and protect your medical information.

As Required by Law

We will disclose medical information about you when required to do so by federal, state or local law.

Multidisciplinary Personnel Teams

We may disclose health information to a multidisciplinary personnel team relevant to the prevention, identification, management or treatment of an abused child and the child’s parents, or elder abuse and neglect.

Special Categories Of Information

In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this notice. For example, there are special restrictions on the use or disclosure of certain categories of information — e.g., tests for HIV or treatment for mental health conditions or alcohol and drug abuse. Government health benefit programs, such as Medi-Cal, may also limit the disclosure of beneficiary information for purposes unrelated to the program.

Right to Inspect and Copy

You have the right to inspect and copy 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. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the 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 associated with your request. We may deny your request to inspect and copy under limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Hospital District 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 medical 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 the information is kept by or for the Hospital District. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your request.

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:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the medical information kept by or for the Hospital District;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete

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. If we prepare a written rebuttal statement to your statement of disagreement with the information in your medical record, we will send you a copy of our rebuttal statement.

Right to an Accounting of Disclosures

You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than our own uses for treatment, payment and health care operations, (as those functions are described above) and with other exceptions pursuant to the law. To request this list or accounting of disclosures, you must submit your request in writing to the Director of Health Information Management. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). 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. In addition, we will notify you as required by law following a breach of your unsecured protected health information.

Right to Request Restrictions

You have the right to request a restriction or limitation on the medical 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 medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had.

We are not required to agree to your request, except to the extent that you request us to restrict disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf (other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special restriction, we can disclose the information to a health plan or insurer for purposes of treating you. If we agree to another special restriction, 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 to the Director of Health Information Management. In 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, for example, disclosures to your spouse.

Right to Request Confidential Communications

You have the right to request that we communicate with you about medical 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 request confidential communications, you must make your request in writing to the Director of Medical Records. We will not ask you the reason for you 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 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 a paper copy of this notice.

Changes to this Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical 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 throughout the Hospital District, and it will also be posted on our web site at www.tfhd.com. In addition, each time you register at or are admitted to the Hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Hospital District or with the Secretary of the Department of Health and Human Services. To file a complaint with the Hospital District, contact the Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

If you require further information about matters covered by this notice, or if you have a complaint, please contact our Privacy Officer at (530) 582-3461, or write to the Secretary of the Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C.

Other uses and disclosures of medical 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 medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, this will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if we have already acted in reliance on your permission. 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.

Tahoe Forest Hospital District (TFHD) Tahoe Forest Hospital District and Incline Village Community Hospital personnel will treat all patients, residents and visitors receiving services from our hospitals, skilled nursing facility, programs and outpatient clinics equally, in a welcoming manner that is free from discrimination based on age, race, color, creed, ethnicity, religion, national origin, marital status, sex, sexual orientation, gender identity or expression, disability, association, veteran or military status, or any other basis prohibited by federal, state, or local law.

Tahoe Forest Hospital District does not exclude people or treat them differently because of race, color, national origin, age, disability, religion, or sex (including pregnancy, sexual orientation, or gender identity). If you believe that Tahoe Forest Hospital District has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, religion, or sex, you can file a grievance with:

Director of Quality and Regulations, Civil Rights Coordinator, TFHD
P.O. Box 759, Truckee, CA 96160
(530) 587-6011
TTY number (530) 582-1112
E-mail: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, contact the Quality and Regulations and Civil Rights Coordinator, TFHD, for assistance.

Civil rights complaints can also be filed with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201
Toll Free: 1-800-868-1019, TDD: 800-537-7697
Fill out a complaint form.

Tahoe Forest Hospital District provides free aids and services to people with disabilities to communicate effectively with us, including:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats)
• Free language services to people whose primary language is not English, including qualified interpreters and information written in other languages

If you need these services, contact the Quality and Regulations Department at TFHD.

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LUS CEEV TSHWJ XEEB: Yog tias koj hais lus Hmoob, muaj cov kev pab cuam txhais lus dawb los pab rau koj. Hu rau 530-587-6011.
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