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

Peninsula Volunteers is required by law to maintain the privacy of your health and service information and to provide you with notice of its legal duties and privacy practices with respect to your health and service information.

OUR PLEDGE REGARDING PRIVATE HEALTH INFORMATION:
We at Peninsula Volunteers understand that the information we maintain about you and your health is personal. We are committed to protecting this information. We create a record of the services you receive at Peninsula Volunteers. 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 service generated by or available to Peninsula Volunteers' workforce (which may include care providers, volunteers, finance staff, information services staff, etc.).

This notice will tell you about the ways in which we may use and disclose protected health and service 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 protected health and service information that identifies you is kept private;
  


• Give you this notice of our legal duties and privacy practices with respect to protected health and service information about you; and
  


• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose protected health and service 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 Service Delivery. We may use health and service information about you to provide you with services. We may disclose protected health and service information about you to other staff member, technicians, students, doctors, nurses, clinicians, interns, or other Peninsula Volunteer personnel who are involved in serving you. For example, a staff member providing family counseling services to you may need to know if you are receiving other services at Peninsula Volunteers in order to make the family counseling services more effective. Different programs/ and departments of Peninsula Volunteers may share health and service information about you in order to coordinate the different things you need, such as assessments and other services. We also may disclose health and service information about you to people outside Peninsula Volunteers who may be involved in your care, or as a part of coordinating follow up care and securing future care. These people may include family members, social workers, school employees, neighbors, clergy, county employees, or others involved in providing services that are part of your care.

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

For Health Care Operations. We may use and disclose health and service information about you for Peninsula Volunteers operations. These uses and disclosures are necessary to run Peninsula Volunteers and make sure that all of our participants receive quality care. For example, we may use protected health and service information to review our services and to evaluate the performance of our staff in caring for you. We may also combine health and service information about many Peninsula Volunteers participants to decide what additional services Peninsula Volunteers should offer, what services are not needed, and whether certain services are effective. We may also disclose information to other staff members, volunteers, interns, and other Peninsula Volunteers personnel for review and learning purposes. We may provide health and service information to representatives of organizations with responsibility for compliance, licensure, quality of care, and funding purposes.

Reminders. We may use and disclose protected health and service information to contact you as a reminder that you have/had an appointment to receive services at Peninsula Volunteers.

Service Alternatives. We may use and disclose protected health and service information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Fundraising/Marketing Activities. We may use protected health and service information about you in Peninsula Volunteers' fundraising efforts. If you do not want Peninsula Volunteers to contact you to participate in our fundraising efforts, you may notify the Fund Development Director in writing.

Individuals Involved in Your Care or Payment for Your Care. We may release protected health and service information about you to a friend or family member who is involved in your care. We may also give information to someone who helps pay for your care. In addition, we may disclose protected health and service 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.

Community Outreach Activities. We may share protected health and service information about you during the course of community outreach activities. An example of this would be a group of clients on an outing to a community performance. Protected health and service information may be shared in the process of securing clients safety and or when conducting supervision.

Research. Under certain circumstances, we may use and disclose protected health and service information about you for research purposes. We will ask your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at Peninsula Volunteers.

Business Associates. There are certain individuals and/or companies that Peninsula Volunteers hires to perform tasks in lieu of permanent staff. Peninsula Volunteers has a contract with each individual or company that includes language to insure that the privacy/confidentiality of each participant that Peninsula Volunteers serves is maintained. As an example, Peninsula Volunteers may hire temporary staff to perform speech therapy functions if a permanent staff member is not available.

THERE MAY BE OTHER SITUATIONS IN WHICH PENINSULA VOLUNTEERS WOULD BE REQUIRED AND PERMITTED TO RELEASE YOUR INFORMATION WITHOUT YOUR AUTHORIZATION OR CONSENT.
As Required By Law. We will disclose health and service 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 protected health and service 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 and service information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose health and service 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 child abuse, elder abuse, or neglect;
• 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 client/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 and service information to social service or health oversight agencies 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 Other Legal Actions. If you are involved in a lawsuit or a legal action, we may disclose health and service information about you in response to a court or administrative order or your signed authorization indicating is it appropriate for us to do so.

Law Enforcement. We may release health and service 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 Peninsula Volunteers; 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.

Coroners, Medical Examiners and Funeral Directors. We may release health and service information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

National Security and Intelligence Activities. We may release health and service 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 and service 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.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding health and service information we maintain about you:

Right to Inspect and Copy. You may have the right to inspect and receive copies of health and service information that may be used to make decisions about your care. This includes service and billing records.

To inspect and request a copy of the health and service information that may be used to make decisions about you, you must submit your request in writing to the Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025. 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 in certain very limited circumstances. If you are denied access to your information, you may request that the denial be reviewed. Another licensed health care professional chosen by Peninsula Volunteers 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 and service 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 Peninsula Volunteers.

To request an amendment, your request must be made in writing and submitted to the Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025. 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:

• Is accurate and complete.
• Was not created by us; unless the person or entity that created the information is no longer available to act on the request to make an amendment;
• Is not part of the health and service information kept by or for Peninsula Volunteers;
• Is not part of the information, which you would be, permitted to inspect and copy

Right to an Accounting of Disclosures. You have the right to request an "accounting of certain disclosures". This is an accounting of the disclosures we made of health and service information about you. This accounting of disclosures of health and service information about you will not include:

• Disclosures needed for service, payment or health care operations.
• Disclosures that we made to you
• Disclosures that were merely incidental to an otherwise permitted or required disclosures
• Disclosures that were made with your written authorization
• Certain other disclosures that we made as allowed or required by law

To request this list or accounting of certain disclosures you must submit your request in writing to the Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025. 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 accounting you request within a 12-month period will be free. For additional accountings, you will be charged 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.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health and service information we use or disclose about you for services, payment or health care operations. You also have the right to request a limit on the health and service 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.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency service.

To request restrictions, you must make your request in writing to our Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025. 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 health and service 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 our Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025. 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 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.

You may obtain a copy of this notice at our website: http://www.peninsulavolunteers.org/privacy_hippa.html.

You can also obtain a paper copy of this notice by calling Chief Privacy Officer at (650) 326-0665.

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 health and service 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 all Peninsula Volunteers offices and sites. The notice will contain on the first page, in the top, the effective date. In addition, each time you register at or are admitted to Peninsula Volunteers for services, 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 Peninsula Volunteers, Inc, or with the Secretary of the Department of Health and Human Services. To file a complaint with Peninsula Volunteers, contact the Chief Privacy Officer at Peninsula Volunteers, 800 Middle Ave, Menlo Park, CA 94025 or (65) 326-0665. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF PROTECTED HEALTH INFORMATION.
Other uses and disclosures of health and service 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 and service 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 and service 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 and or services that we provided to you.

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Peninsula Volunteers, Inc.
800 Middle Avenue
Menlo Park, CA 94025
Telephone: 650-326-0665
Fax: 650-326-9547