Effective Date: September 23, 2013NOTICE OFPRIVACY PRACTICEUNIVERSITY OF CALIFORNIASAN FRANCISCO UCSF HEALTH SYSTEMTHIS NOTICE DESCRIBES HOW HEALTHINFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESSTO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.862-082 (Rev. 09/13) WorkflowOneUNIVERSITY OF CALIFORNIA, SAN FRANCISCONOTICE OF PRIVACY PRACTICE
UCSF Health SystemUCSF Health System is one of the health care componentsof the University of California. The Universityof California health care components consist of theUC medical centers, the UC medical groups, clinicsand physician offices, the UC schools of medicineand other UC health professional schools, departmentsengaged in clinical care, the student healthservice areas on some campuses, employee healthunits on some campuses, and the administrative andoperational units that are part of the health care componentsof the University of California.Our Pledge RegardingYour Health InformationUCSF Health System is committed to protectingmedical, mental health and personal informationabout you (“Health Information”). We are required bylaw to maintain the privacy of your Health Information;provide you information about our legal dutiesand privacy practices; and inform you of your rightsand the ways in which we may use Health Informationand disclose it to other entities and persons.1How We May Use and Disclose HealthInformation About YouThe following sections describe different ways thatwe may use and disclose your Health Information.Some information; such as certain drug and alcoholinformation, HIV information, genetic information andmental health information; is entitled to specialrestrictions related to its use and disclosure. Notevery use or disclosure will be listed. All of the wayswe are permitted to use and disclose information,however, will fall within one of the following categories.Other uses and disclosures not described inthis Notice will be made only if we have your writtenauthorization.
8Other Uses and Disclosuresof Health InformationOther uses and disclosures of Health Information not coveredby this Notice will be made only with your writtenauthorization. If you authorize us to use or disclose yourHealth Information, you may revoke that authorization, inwriting, at any time. However, the revocation will not beeffective for information that we have already used and disclosedin reliance on the authorization.Your Rights RegardingYour Health InformationYour Health Information is the property of UCSF HealthSystem. You have the following rights regarding theHealth Information we maintain about you:Right to Inspect and Copy. With certain exceptions, youhave the right to inspect and/or receive a copy of yourHealth Information. If we have the information in electronicformat then you have the right to get your Health Informationin electronic format if it is possible for us to do so. If not wewill work with you to agree on a way for you to get the informationelectronically or as a paper copy.To inspect and/or to receive a copy of your Health Information,you must submit your request in writing to Health InformationManagement Services, UCSF Medical Center, 400Parnassus Ave., Room A-88, San Francisco, CA 94143-0308. If you request a copy of the information, there is a feefor these services.We may deny your request to inspect and/or to receive acopy in certain limited circumstances. If you are deniedaccess to Health Information, in most cases, you may havethe denial reviewed. Another licensed health care professionalchosen by UCSF Health System will review yourrequest and the denial. The person conducting the reviewwill not be the person who denied your request. We willcomply with the outcome of the review.Right to Request an Amendment or Addendum. If you feelthat Health Information we have about you is incorrect orincomplete, you may ask us to amend the information or addan addendum (addition to the record). You have the right torequest an amendment or addendum for as long as the informationis kept by or for UCSF Health System.Amendment. To request an amendment, your request mustbe made in writing and submitted to Patient Relations, UCSFMedical Center, 350 Parnassus Ave., Suite 150, Box 0208,San Francisco, CA 94143-0208, phone 1-415-353-1396, fax1-415-353-8556. You must be specific about the informationthat you believe to be incorrect or incomplete and you mustprovide a reason that supports the request.We may deny your request for an amendment if it is not inwriting, we cannot determine from the request the informationyou are asking to be changed or corrected, or yourrequest does not include a reason to support the change oraddition. In addition, we may deny your request if you ask usto amend information that:• Was not created by UCSF Health System;• Is not part of the Health Information kept by or for UCSFHealth System;• Is not part of the information which you would be permittedto inspect and copy; or• UCSF Health System believes to be accurate and complete.Addendum. To submit an addendum, the addendum mustbe made in writing and submitted to Patient Relations, UCSFMedical Center, 350 Parnassus Ave., Suite 150, Box 0208,San Francisco, CA 94143-0208, phone 1-415-353-1396, fax1-415-353-8556. An addendum must not be longer than 250words per alleged incomplete or incorrect item in yourrecord.Right to an Accounting of Disclosures. You have the rightto receive a list of certain disclosures we have made of yourHealth Information.9UNIVERSITY OF CALIFORNIA, SAN FRANCISCONOTICE OF PRIVACY PRACTICE
Changes to UCSF Health System’sPrivacy Practice and This NoticeWe reserve the right to change UCSF Health System’sprivacy practices and this Notice. We reserve the rightto make the revised or changed Notice effective forHealth Information we already have about you as wellas any information we receive in the future. We willpost a copy of the current Notice throughout UCSFHealth System. In addition, at any time you mayrequest a copy of the current Notice in effect.12Questions or ComplaintsIf you have any questions about this Notice, pleasecontact Patient Relations, UCSF Medical Center, 350Parnassus Ave., Suite 150, Box 0208, San Francisco,CA 94143-0208, phone 1-415-353-1396, fax 1-415-353-8556.If you believe your privacy rights have been violated,you may file a complaint with UCSF Health System orwith the Secretary of the Department of Health andHuman Services, Office for Civil Rights. To file a writtencomplaint with UCSF Health System contactPatient Relations, UCSF Medical Center, 350 ParnassusAve., Suite 150, Box 0208, San Francisco, CA94143-0208, phone 1-415-353-1396, fax 1-415-353-8556. You will not be penalized for filing a complaint.