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Notice of Privacy Practices


Notice of Privacy Practices Form in English

Notice of Privacy Practices- Form in Spanish

About This Notice

We are required by law to maintain the privacy of Protected Health Information and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your Protected Health Information, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.

What is Protected Health Information? 

“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.

How We May Use and Disclose Your Protected Health Information 

We maintain and share health and financial related records about you in both paper and electronic form.  We use this information and disclose it to others for the following purposes:

Treatment.  We use your health information to provide health care to you and to coordinate your health care with other providers, and we disclose it to other health care providers electronically to enable them to provide health care services to you.  For example, if we refer you to a specialist physician we send all or a part of your health record to the specialist to assist him or her in evaluating and treating you.  If your provider is a Participant of a Health Information Exchange your records will visible to other providers that are Participants in the Exchange.

Payment.  We use and disclose your health information to obtain payment for health care services we provide to you, including determining your eligibility for benefits.  For example, we may send a claim to your insurer that contains information about the services we provided to you, or we may send a bill to a family member who is responsible for paying for your care.

Health care operations.  We use and disclose your health information as necessary to enable us to operate our medical practice.  For example, we use our patients’ claims information for our internal financial accounting activities, and we review health records to ensure quality.

We also disclose health information to our Business Associates who assist us in these functions, but we obtain a confidentiality agreement from them before we make such disclosures for payment or operational purposes.  For example, companies that provide or maintain our computer systems may have access to computerized health information in the course of providing services to us.

Contacting you.  We may contact you to provide appointment reminders or information about treatment options available to you.  We may also contact you about other health-related services that may interest you. 

Others involved in your care.  Unless you object, we may disclose medical information to a friend or family member who is involved in your care, to the extent we judge necessary for their participation.

Other Disclosures.  We may disclose health information without your authorization to government agencies and private individuals and organizations in a variety of circumstances in which we are required or authorized by law to do so.  Here are the general kinds of disclosures we may be required or allowed to make without your authorization:

    • Disclosures that are required by state or federal law

    • Disclosures to public health authorities or to other persons in connection with public health activities

    • We may disclose Protected Health Information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.

    • Disclosures to agencies responsible for overseeing the health care system, for audits, inspections or investigations

    • Disclosures for judicial and administrative proceedings, such as lawsuits

    • Disclosures to law enforcement agencies

    • Disclosures to coroners and medical examiners

    • Disclosures to organ procurement agencies, if you are an organ donor or a possible donor

    • Disclosures to researchers conducting research under the auspices of an Institutional Review Board or privacy board

    • Disclosures to avert a serious threat to health or safety

    • If you are a member of the armed forces or a veteran, we may release health information to your military command authority or to the veterans’ administration to assist in determining your eligibility for veterans’ benefit Disclosures to assist authorized federal officials in national security activities, or for the provision of protective services to officials

    • 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 institution or official

    • Disclosures to other agencies administering government health benefit programs, as authorized or required by law

    • Disclosures to comply with workers’ compensation laws.

    • We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

    • Disclosures to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.

    • We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications.

Limitations.   In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described above.  For example, government health benefit programs may limit the disclosure of health information for purposes unrelated to the program.  In addition, there are special restrictions on the disclosure of health information relating to HIV/AIDS status, mental health treatment, developmental disabilities, and drug and alcohol abuse treatment.  We comply with these restrictions in our use of your health information.

Authorization.  Except as described above, we will not permit other uses and disclosures of your health information without your written authorization, which you may revoke at any time in the manner described in our authorization form.

Your Rights Regarding Your Protected Health Information 

You have the following rights, subject to certain limitations, regarding your Protected Health Information:

    • You have the right to ask us to restrict certain uses and disclosures of your health information.  However, we are not required to agree to any restrictions requested by our patients.

    • You have the right to receive confidential communications from us, for example by asking us to contact you at a particular telephone number, post office box or other address.

    • You have the right to inspect and copy any certain records that we maintain.  These include our medical records and billing records concerning you. Under certain circumstances, we may deny your request.  If your request is denied, we will tell you the reason why in writing.  You have the right to appeal the denial.

    • If you feel the information in our records is wrong, you have the right to request us to amend the records.    We may deny your request in certain circumstances.  If your request is denied, you have the right to submit a statement for inclusion in the record. 

    • You have the right to receive a report of non-routine disclosures that we have made of your health information, up to six years prior from the date of your request.   There are some exceptions: for example, we do not maintain records of disclosures made with your authorization; disclosures made for the purposes of treatment, obtaining payment for health services, or operating our medical practice; disclosures made to you; and certain other disclosures.

    • You have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity for any record we maintain in electronic format. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with sending (electronic or hard copy) your medical record.

    • You have the right to be notified upon a breach of any of your unsecured Protected Health Information. 

    • If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

    • If you received this notice electronically, you have the right to request a paper copy from us at any time.

    • You have the right to opt-out of the Health Information Exchange.  Your physician can provide you with more information or visit

The foregoing is a general statement of your rights.  They are subject to all limitations permitted or required by law.

How do I exercise these rights?  You can exercise any of your rights by sending a written request to our Privacy Official at the address below. We encourage you to call our office and speak to us if you have any questions or concerns.

Clinic Manager, Santa Cruz Women’s Health Center, 250 Locust Street, Santa Cruz, CA 95060. Call 831-427-3500

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights,, for more information. There will be no retaliation against you for filing a complaint.

Santa Cruz Community Health is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,930,819, with 91% financed with nonfederal government sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit