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Minimum Necessary Standard. When using or disclosing your PHI or when requesting your PHI from another covered entity, BHC Alhambra Hospital will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply in the following situations:

• Disclosures to or requests by a health care provider for treatment;
• Uses or disclosures made to you;
• Uses or disclosures made pursuant to an authorization;
• Disclosures made to the Secretary of the U.S. Department of Health and Human Services;
• Uses or disclosures that are required by law; or
• Uses or disclosures that are required for BHC Alhambra Hospital's compliance with legal regulations.

Your Rights Under the Federal Privacy Standard

Although your health records are the physical property of the healthcare provider who completed them, you have certain rights with regard to the information contained therein.

1. You have a right to request restrictions on uses and disclosures of your health information by submitting a request in writing. The right to request restriction does not extend to certain uses or disclosures permitted or required by law, such as uses or disclosures for public health activities. In those cases, you do not have a right to request restriction. BHC Alhambra Hospital is not required to agree to your requested restriction. However, if BHC Alhambra Hospital does agree to a restriction, it will comply with the restriction unless the information is needed to provide emergency treatment to you, or the disclosure is otherwise required under federal regulations.

2. You have the right to request how and where BHC Alhambra Hospital contacts you about PHI. For example, you may request that BHC Alhambra Hospital contact you at your work address or phone number. Your request must be in writing. BHC Alhambra Hospital is required to accommodate all reasonable requests.

3. You have the right to obtain a paper copy of this Notice at any time by contacting the facility Privacy Official. BHC Alhambra Hospital will provide a copy of this Notice no later than the date you first receive treatment at the facility, except in emergency situations, and then BHC Alhambra Hospital will provide the Notice to you as soon as reasonably practicable after the emergency treatment situation.

4. You have the right to inspect and copy your PHI upon the submission of a written request. Again, this right is not absolute and in certain situations, BHC Alhambra Hospital can deny access - for example, if a licensed health care professional believes that access to such information could cause harm to your physical or mental well-being.

You do not have a right of access to the following:

• Psychotherapy notes. These include notes that are recorded in any medium by a mental health professional documenting or analyzing a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of your medical record.
• Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
• Protected Health Information (PHI) that is subject to the Clinical Laboratory Improvement Amendments of 1988 ("CLIA"), 42 U.S.C. § 263a, to the extent that the provision of access to the individual would be prohibited by law.
• Information obtained from someone other than a healthcare provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

In other situations, the provider may deny you access, but if it does, the provider must provide you with an opportunity to have the denial reviewed by another licensed professional within 60 days of the denial. These "reviewable" grounds for denial include:

• Licensed healthcare professional has determined, in the exercise of professional judgment, that the access is reasonably likely to endanger the life or physical safety of the individual or another person.
• Protected Health Information makes reference to another person (other than a healthcare provider) and a licensed healthcare provider has determined, in the exercise of professional judgment, that providing access is reasonably likely to cause substantial harm to such other person.
• The request is made by the individual's personal representative and a licensed healthcare professional has determined, in the exercise of professional judgment, that providing access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.

If BHC Alhambra Hospital denies you access to your PHI, BHC Alhambra Hospital will explain why and what your rights are, including how to seek review. If BHC Alhambra Hospital grants access to your PHI, BHC Alhambra Hospital will give you instructions on any additional steps, if needed, for you to have access the information. BHC Alhambra Hospital reserves the right to charge a reasonable fee for making copies of the requested PHI.

You have the right to request in writing amendment of your PHI. BHC Alhambra Hospital may deny your request if:

• BHC Alhambra Hospital did not create the record, unless you provide a reasonable basis to believe that the originator of the PHI is no longer available to act on the requested amendment.
• The records are not available for your access, as discussed above in number 4.
• The record is accurate and complete.
• The PHI that is the subject of your request is not maintained by or for BHC Alhambra Hospital.

If BHC Alhambra Hospital denies your request for amendment, BHC Alhambra Hospital will notify you why and how you can submit a written statement disagreeing with the denial (which may be rebutted by BHC Alhambra Hospital) and how you can complain to BHC Alhambra Hospital about the denial.

If BHC Alhambra Hospital grants the request, BHC Alhambra Hospital will make the correction and distribute the correction to those who need it and those you identify to BHC Alhambra Hospital that you want to receive the corrected information.

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