Joint Notice of Privacy Practices
This Joint Notice of Privacy Practices (Notice) describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Who Does This Notice Apply To
This Notice describes the privacy practices of Hoag Orthopedic Institute and each of the Affiliated Covered Entities identified below (collectively referred to as "HOI"). This Notice applies to physicians, allied health professionals, other healthcare providers, staff, and other personnel providing services to you at an HOI facility.
Unless otherwise stated, all these HOI facilities follow the terms of this Notice. In addition, these HOI facilities may share health information with each other for treatment, payment or health care operations as described in this Notice. This Notice applies to all of the records of your care generated at HOI whether made by HOI personnel or your treating physician when caring for you at an HOI facility, unless your individual provider gives you their own notice of privacy practices that describes how they will protect your health information. Your personal doctor may have different policies or notices regarding their use and disclosure of your health information created in their office or clinic.
AFFILIATED COVERED ENTITIES
For purposes of the HOI Notice of Privacy Practices required under the
Federal Standards for Privacy of Individually Identifiable Health Information
as found in 45 CFR Parts 160 and 164 ("Privacy Rule), and for all
allowable purposes of compliance with the Privacy Rule, the following,
separate, affiliated covered entities have designated themselves as a
single affiliated covered entity effective as of July 1, 2019, and as
subsequently amended:
Hoag Orthopedic Institute, LLC
16250 Sand Canyon Avenue
Irvine, CA 92618
Orthopedic Surgery Center of Orange County, LLC
dba Hoag Orthopedic Institute Surgery Center
22 Corporate Plaza Dr., Suite #150
Newport Beach, CA 92660
Orthopedic Surgery Center of Orange County, LLC
dba Hoag Orthopedic Institute Surgery Center
Aliso Viejo 15 Mareblu, Suite #100
Aliso Viejo, CA 92656
Main Street Specialty Surgery Center, LLC
dba Hoag Orthopedic Institute Surgery Center Orange
280 N. Main St., Suite #100
Orange, CA 92868
California Specialty Surgery Center, LLC
26371 Crown Valley Parkway
Mission Viejo, CA 92691
Hoag Orthopedic Institute Surgery Center Beverly Hills, LLC
9090 Wilshire Boulevard., Suite #102
Beverly Hills, CA 90211
Our Responsibility To You Regarding Your Health Information
We understand that your health information is personal. We are committed to protecting the privacy of your health information. We create a record of the care and services you receive at HOI. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.
We are required by law to:
- Make sure that health information that identifies you is kept private (with certain exceptions);
- Give you this Notice of our legal duties and privacy practices with respect to health information about you; and follow the terms of the Notice that is currently in effect.
- Notify you if we are unable to agree to a restriction that you have requested.
- Accommodate your reasonable requests to communicate your health information by alternative means or at alternative locations.
- Notify you following a breach of your unsecured health information, as required by law.
How We May Use and Disclose Health Information About You
We typically use or disclose your health information for the following reasons:
For Treatment
We may use health information about you to provide you with health treatment
or services. 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 dietitian if you have diabetes
so that we can arrange for appropriate meals. At the hospital, different
departments may share health information about you in order to coordinate
the different things you need, such as prescriptions, lab work and X-rays.
We also may disclose health information about you to people, places and
entities outside of HOI who may be involved in your health care after
you leave HOI, such as skilled nursing facilities, home health agencies,
and physicians or other practitioners.
For Payment
We may use and disclose health information about you so that the treatment
and services you receive at HOI 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 surgery you received at
HOI so your health plan will pay us or reimburse you for the surgery.
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 HOI who are involved in your care, to assist them in obtaining
payment for services they provide to you. However, we cannot disclose
information to your health plan for payment purposes, if you ask us not
to and you are paying for the services yourself.
For Health Care Operations
We may use and disclose health information about you for health care operations.
These uses and disclosures are necessary to operate HOI and make sure
that all 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 combine health information
about many patients to decide what additional services HOI 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 facility personnel for review and learning purposes.
We may also combine the health information we have with health information
from other healthcare facilities 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 health information so
others may use it to study health care and health care delivery without
learning who the specific patients are.
Unless you instruct us otherwise, we may also use or disclose your health
information for the following purposes:
Individuals Involved in Your Care or Payment for Your Care.
We may release health information about you to a friend or family member
who is involved in your medical care. We may also give information to
those you identify as responsible for payment of your care. In addition,
we may 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. If you wish to “opt-out” from
having your information disclosed to a family member, please notify the
admission staff.
Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at the hospital, if applicable. 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. If you wish to “opt-out” of the hospital directory, please notify the admission staff.
Health Information Exchange. Hoag Orthopedic Institute (hospital) participates in a community Health Information Exchange (HIE), an electronic system through which the hospital and other providers can share patient information according to nationally- recognized standards and in compliance with federal and state law that protects your privacy. Through the HIE, your participating providers will be able to access information about you that is necessary for your treatment, unless you choose to have your information withheld from the HIE by personally opting out from participation. If you choose to opt out of the HIE (that is, if you feel that your health information should not be shared through theHIE), Hoag Orthopedic Institute will continue to use your health information in accordance with this Notice of Privacy Practices and the law, but will not make it available to others through the HIE. To opt-out of the HIE at any time, contact the Hoag Health Information Management Department at (949) 764-8326, Option 5 or email HoagMedicalRecords@hoag.org.
Other Required Uses & Disclosures
We may also be required to use or disclose health information about you without your prior authorization for the following purposes:
Business Associates. There are some services provided through contracts that we have with business associates. For example, HOI and Hoag Memorial Hospital Presbyterian are business associates, and we may provide your health information to Hoag in order to coordinate your care and for purposes of health care operations.
A company who bills insurance companies on our behalf is also our business associate, and we may provide your health information to such a company so the company can help us obtain payment for the health care services we provide. To protect your health information, we require our business associates to appropriately safeguard your information through a written agreement.
Research. Under certain circumstances, we may use and disclose health information about you for research purposes. All research projects, however, are subject to a special approval process. This process 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.
As Required By Law. We will disclose health information about you when required to do so by federal, state or local law or in response to valid judicial or administrative orders.
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.
Organ and Tissue Donation. 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.
Coroners, Medical Examiners & Funeral Directors. We may release health 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 health information about patients to funeral directors as necessary to carry out their duties.
Military and Veterans. If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.
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.
Public Health Activities. We may disclose health information about you as required or permitted by law to public health authorities or government agencies whose official activities include preventing or controlling disease, injury, or disability. These disclosures include reporting communicable diseases, reactions to medications, problems with products or adverse events, for immunization registries, reporting abuse or neglect, or for vital statistics such as reporting births or deaths.
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 (which may include written notice to you) 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: • 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 criminal conduct at the hospital; 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.
National Security. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may also 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.
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 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.
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 in cases of elder abuse and neglect.
Special Categories of Information
Federal or State Privacy Protections. In some circumstances, your health information may be subject to special privacy protections under federal and state laws 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 the following types of information: (i) alcohol and substance use disorder records; (ii) HIV/AIDS testing, diagnosis, or treatment information; (iii) mental health records and psychotherapy notes and (iv) sexual and reproductive health issues, such as sexually transmitted diseases or pregnancy.
Reproductive Health Information. Without your written authorization, we are prohibited from using or disclosing reproductive health information about you for the purpose of a criminal, civil, or administrative investigation or proceeding against any person in connection with seeking, obtaining, providing, or facilitating reproductive health care that is lawful under the circumstances in which such health care is provided, or to identify any person for the purpose of initiating such activities. For example, we would be prohibited from disclosing health information related to reproductive health care to a law enforcement officer to aid in the investigation of a patient who may have sought a lawful abortion. In addition, prior to using or disclosing health information potentially related to reproductive health care for purposes of health oversight activities, judicial and administrative proceedings, law enforcement, or providing information about decedents to coroners and medical examiners, the requesting party is required to provide a valid attestation verifying that the requested use or disclosure is not otherwise prohibited by federal law. For example, a disclosure of health information related to reproductive health care in response to a court order would be permissible provided that such disclosure is limited to health information expressly authorized under the order and a valid order is provided.
Other Uses Or Disclosures of Health Information
In any other situation not covered by this Notice, we will ask for your written authorization before disclosing your health information. Specific examples of disclosures requiring your authorization include (i) disclosure at your request for reasons other than as covered by this Notice; (ii) disclosure that constitutes the sale of your health information; and (iii) use or disclosure of your health information for prohibited marketing communications under federal law. 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, this will stop any further use or disclosure of your health information for the purposes covered by your written authorization, except if we have already acted on 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.
To the extent required by law, when using or disclosing your health information or when requesting your health information from another covered entity, we will make reasonable efforts not to use, disclose or request more than a limited data set of your health information or if needed by us, no more than the minimum amount of health information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.
Your Rights Regarding Health Information About You
You have the following rights regarding health information we maintain about you:
- To request in writing a restriction on certain uses or disclosures of your health information for treatment, payment or health care operations (e.g., a restriction on who may access your health information). Although we will consider your request, we are not legally required to agree to a requested restriction, except we must agree to your written request that we restrict a disclosure of information to a health plan if the information relates solely to an items or service for you have paid out of pocket in full. We are required to abide by such a request, unless we are otherwise required to make the disclosure. It is your responsibility to notify any other providers about this restriction.
- To obtain a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically, by contacting the applicable HOI facility’s admitting or registration department staff.
- To inspect and obtain a copy of your health information, in most cases. If you request a copy (paper or electronic), we may charge you a reasonable, cost-based fee.
- To request in writing an amendment to your records if you believe the information in your record is incorrect or important information is missing. We could deny your request to amend a record if the information is not created by us, is not maintained by us, or if we determine the record is accurate. You may appeal, in writing, a decision by us not to amend your record. Even if we deny your request for amendment, you have the right to submit a written addendum with respect to any item or statement in your record you believe is incomplete or incorrect.
- To obtain an accounting of certain disclosures we have made of your health information. The accounting will provide information about disclosures made outside of HOI for purposes other than treatment, payment, health care operations or where you specifically authorized a use or disclosure in the past six (6) years. The request must be in writing and state the time period desired for the accounting. The first list you request will be free. For additional requests, there may be a charge for additional requests made within a twelve (12) month period.
- To request that health information about you be communicated to you in a certain way or at a certain location. For example, you can ask that we only contact you at home or by mail.
Except as otherwise noted, all written requests or appeals should be submitted to the HOI Privacy Officer listed below.
Changes to this Notice
We reserve the right to change this Notice. If a change in our practices is material, we will revise this Notice to reflect the change. 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 at each HOI facility. The notice will contain the effective date on the last page. In addition, each time you register at or are admitted to HOI 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 HOI or with the Secretary of the U.S. Department of Health and Human Services; Office of Civil Rights, 200 Independence Ave., S.W. Washington, D.C. 20201.
To file a complaint with HOI, contact:
Hoag Orthopedic Institute - Compliance Office
Attn: Privacy Officer
16250 Sand Canyon Avenue
Irvine, CA 92618
HOICorporateCompliance@hoag.org
(949) 727-5020
All complaints must be submitted in writing. You will not be penalized
for submitting a complaint.
Effective Date: May 15, 2025