How this Medical Practice May use or disclose Your Health Information

This medical practice collects health information about you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

Treatment. We disclose medical information to our employees and others who are involved in providing the care you need. We may share your PHI with other health care providers who will provide services which we do not provide. We may also disclose medical information to a family member, relative, close friend, or any other person you identify that is involved in your medical care or for payment for care.

Health Care Operations. We may use and disclose your protected health information to support the business activities of our practice. For example — we may use medical information about you to review and evaluate our teatment and services or to evaluate our staff’s perfomance while caring for you. In addition, we may disclose your PHI to third party business associates who perform billing, consulting or transcription services for our practice.

Payment. We use and disclose medical information about you to obtain payment for the services we provide. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
Appointment Reminders. We will use and disclose your PHI to contact you as a reminder about scheduled appointments or treatments.
Sign in sheet. We may use and disclose medical information about you by having you sign in when you arrive. We may also call out your name when we are ready to see you.

Public health. We may disclose your PHI, as required by law, to public health authorities for purposes related to: preventing or controlling disease, injury, or disablitiy: reporting child, elder or dependent adult abuse or neglect: reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

Research. We may use and disclose your PHI to re- searchers provided the research has been approved by an institutional review board that has reviewed the re- search proposal and established protocols to ensure the privacy of the health information.
Required by law. We will use and disclose your PHI when required to by federal, state, or local law. You will be notified of any such disclosures.

Worker’s Compensation. We may disclose your PHI as necessary to comply with worker’s compensation laws. For example, to the extent your care is covered by worker’s compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury/illness to the employer or worker’s compensation insurer.

Judicial and administrative proceedings We may, as required by law, disclose your PHI in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process.

Marketing. We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services that my be of interest to you. We may also encourage you to purchase a product or service when we see you. We will not otherwise use or disclose your medical information for marketing purposes without your written authorization.

Uses or Disclosures Not Covered

Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health infomation for another purpose, you may revoke your authorization in writing at any time.

Your Health Information Rights

Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information, by a written request specifying what information you want to limit and what limitations on our use of disclosure of that in- formation you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision.

Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communciations.

Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by California and federal law. Any psychotherapy notes that may have been included in these records are not available for your inspection or copying by law.

You may mail in your request, or bring it to our of- fice. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice’s denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures. You have the right to request a list of the disclosures of your health in-formation we have made outside of our practice that were not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates prior to April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal obligation to retain information).

Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist or by calling and asking us to mail you a copy.

Changes to this Notice of Privacy Practices. We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment. We will also post the current notice on our website.

Complaints. Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer.

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building Washington, DC 20201