Your Right to Privacy

Notice of Privacy Practices

Effective: April 14, 2003

THIS NOTICE EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

CalOptima provides you access to health care for the Medi-Cal program. We are required by state and federal law to protect your health information. We must give you this notice to let you know your rights and how we may use and share your information.

Your information is personal and private.

After you become eligible and enroll in our health plan, Medi-Cal sends your information to us. We also receive medical information from your doctors, clinics, labs and hospitals in order to approve and pay for your health care.

CalOptima requires its employees to follow CalOptima privacy and security policies and procedures to protect your health information in oral (for example, when discussing your health information with authorized individuals over the telephone or in person) written or electronic form.

CHANGES TO NOTICE OF PRIVACY PRACTICES

CalOptima must obey the notice currently in effect. We have the right to change these privacy practices. If we make changes after April 14, 2003, we will revise this notice and send it to you right away.

HOW WE MAY USE AND SHARE INFORMATION ABOUT YOU

Your information may be used or shared by CalOptima only for a reason directly connected to the Medi-Cal program. The information we use and share includes, but is not limited to:

  • Your name
  • Address
  • Personal facts
  • Medical care given to you
  • Your medical history

Some actions we take when we act as a Medi-Cal Health Plan include:

  • Checking your eligibility, enrollment and amount of medical aid
  • Approving, giving and paying for Medi-Cal services
  • Investigating or prosecuting Medi-Cal cases (like fraud)
  • Checking the quality of care that you receive
  • Coordinating the care you receive

Examples:

  1. For treatment: You may need medical treatment that requires us to approve care in advance. We will share information with doctors, hospitals and others in order to get you the care you need.
  2. For payment: CalOptima reviews, approves and pays for health care claims sent to us for your medical care. When we do this, we share information with the doctors, clinics and others who bill us for your care. We may also forward bills to other health plans or organizations for payment.
  3. For health care operations: We may use information in your health record to judge the quality of the health care you receive. We may also use this information in audits, fraud and abuse programs, planning, and general administration.

OTHER USES FOR YOUR HEALTH INFORMATION

  1. Sometimes a court will order us to give out your health information. We will also give information to a court, investigator or lawyer if it is about the operation of Medi-Cal. This may involve fraud or actions to recover money from others, when Medi-Cal has paid your medical claims.
  2. You or your doctor, hospital and other health care providers may appeal decisions made about claims for your Medi-Cal care. Your health information may be used to make these appeal decisions.
  3. We may also share your health information with agencies and organizations that which check how our health plan is providing services.
  4. We must share your health information with the federal government when it is checking on how we are meeting privacy rules.

WHEN WRITTEN PERMISSION IS NEEDED

If we want to use your information for any purpose not listed in this notice, we must get your written permission. If you give us your permission, you may take it back in writing at any time.

WHAT ARE YOUR PRIVACY RIGHTS?

  • You have the right to ask us not to use or share your personal health care information in the ways described in this notice. We may not be able to agree to your request.
  • You have the right to ask us to contact you only in writing, or at a different address or post office box, or by telephone. We will accept reasonable requests when necessary to protect your safety.
  • You and your personal representative have the right to get a copy of your health information. You will be sent a form to fill out and may be charged a fee for the costs of copying and mailing records. We may keep you from seeing certain parts of your records for reasons allowed by law.
  • You have the right to ask that information in your records be changed if it is not correct or complete. We may refuse your request if: 1.) The information is not created or kept by CalOptima, or 2.) We believe it is correct and complete.
  • If we don’t make the changes you ask, you may ask that we review our decision. You may also send a statement saying why you disagree with our records, and your statement will be kept with your records.

**IMPORTANT**
CalOptima DOES NOT HAVE COMPLETE COPIES OF YOUR MEDICAL RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR CHANGE YOUR MEDICAL RECORDS, PLEASE CONTACT YOUR DOCTOR OR CLINIC.

  • When we share your health information after April 14, 2003, you have the right to request a list of:
  1. With whom we shared the information
  2. When we shared it
  3. For what reasons
  4. What information was shared

This list will not include when we share information with you, with your permission, or for treatment, payment or health plan operations.

You have a right to request a paper copy of this Notice of Privacy Practices. You can also find this notice on our website at www.caloptima.org

HOW TO CONTACT US TO USE YOUR RIGHTS

If you want to use any of the privacy rights explained in this notice, please call or write us at:

Privacy Officer
CalOptima
505 City Parkway West
Orange, CA 92868
1-888-587-8088

OR

CalOptima Customer Service Department
1-714-246-8500
Toll-free at 1-888-587-8088
Members with hearing or speech impairments can call the TDD/TTY line at 1-714-246-8523

COMPLAINTS

If you believe that we have not protected your privacy and wish to file a complaint or grievance, you may write or call CalOptima at the address and phone number above. You may also contact the agencies below:

Privacy Officer
California Department of Health Services
1501 Capitol Avenue, MS 4721 P.O. Box 997413
Sacramento, CA 95899-7413
1-916-445-4646 or TDD/TTY 1-877-735-2929
Website: dhcs.ca.gov/privacyoffice

OR

U.S. Department of Health and Human Services
Office for Civil Rights
Attention: Regional Manager
90 7th Street, Suite 4-100
San Francisco, CA 94103
For additional information, call 1-800-368-1019
or
U.S. Office for Civil Rights at 1-866-OCR-PRIV (1-866-627-7748)
or TDD/TTY 1-866-788-4989

USE YOUR RIGHTS WITHOUT FEAR

CalOptima cannot take away your health care benefits or do anything to hurt you in any way if you choose to file a complaint or use any of the privacy rights in this notice.

QUESTIONS

If you have any questions about this notice or want more information, please contact the CalOptima Privacy Officer at the address and phone number from above.

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