NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice
takes effect on April 15, 2003, and remains in effect until we replace it.
The privacy of your medical information is important to us. We understand that your medical information is personal and we
are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record
to provide you with quality care and to comply with certain legal requirements. This Notice will tell you about the way we
may use and share medical information about you. We also describe your rights and certain duties we have regarding the use
and disclosure of medical information.
Law Requires Us To:
1. Keep your medical information private.
2. Give you this Notice describing our legal duties, privacy practices and your rights regarding your medical information.
3. Follow the terms of the Notice that is currently in effect.
We Have The Right To:
1. Change our privacy practices and the terms of this Notice at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our Notice effective for all medical information that
we keep, including information previously created or received before the changes.
Notice Of Change To Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this Notice and make the new notice
available upon request.
The following section describes different ways that we use and disclose medical information without your consent or
authorization. Not every use or disclosure will be listed. However, we have listed all the different ways we are permitted to
use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below
without your specific written authorization. Any specific written authorization you provide may be revoked at any time by
writing to us.
For Treatment: We need your medical information about you to provide you with medical treatment or services. We may
disclose medical information when you need a prescription, x-ray, lab work or other health care services. We may use and
disclose medical information when referring you to another health care provider.
Payment: We may use and disclose medical information about you so that we can bill and collect payment for the treatment
and services provided to you.
Health Care Operations: We may use and disclose your medical information for our health care operations. This might
include measuring and improving quality, evaluating employee performances, conducting training programs and getting the
accreditation, certificates, licenses and credentials we need to serve you.
Additional Uses And Disclosures: Medical information to notify or help notify: a family member, your personal
representative or another person responsible for your care. We will share information about your location, general condition or
death. If you are present, we will obtain your permission if possible before we share, or give you the opportunity to refuse
permission. In case of emergency and if you are not able to give or refuse permission, we will share only the health
information that is directly necessary for your health care, according to our professional judgement. We will also use our
professional judgement and experience to make reasonable decisions about your best interests in allowing a person to act on
your behalf to pick-up medicine, prescriptions, supplies or medical information for you.
Required by Law: We may use and disclose medical information as required by federal, state or local law to the extent that the
use or disclosure complies with the law and limited to the requirements of the law.
Public Health Activities: As required by law, we may disclose your medical information to the public health or legal
authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also
disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of
reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements to
track products or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized
to do so by law, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting
or spreading a disease or condition.
Abuse, Neglect or Domestic Violence: We may disclose medical information in certain cases to appropriate authorities if we
have reason to believe that a patient has been a victim of domestic violence, abuse or neglect.
Health Oversight Activities: We may disclose medical information to an agency providing health oversight activities authorized
by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary
actions, or other authorized activities.
Lawsuits or Other Legal Proceedings: We may disclose medical information in response to a court or administrative order,
subpoena, discovery request, or any other lawful process under certain circumstances. Under limited circumstances, such as a
court order, warrant or grand jury subpoena, we may share your medical information with law enforcement officials. We may
share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material
witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody
with a law enforcement official or correctional institution under certain circumstances.
Research: Medical information for research purposes in limited circumstances where the research has been approved by a
review board that has reviewed the research proposal and established protocols that ensure the privacy of the medical
Funeral Director, Coroner or Medical Examiner: To help them carry out their duties, we may share the medical information
of a person who has died with a coroner, medical examiner, funeral director or an organ procurement organization.
Workers Compensation: We may disclose health information as authorized by workers compensation laws or other similar
programs that provide benefits for work-related injuries or illness.
You Have The Right To:
1. Inspect or obtain copies of your medical information. You must make your request in writing to the Privacy Official
listed at the end of this Notice. We may charge a reasonable fee for copy of records.
2. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required
to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of emergency).
3. Request that we communicate with you about your medical information by different means or to different locations.
You must make your request in writing. We are required to accommodate only reasonable requests.
4. Request that we amend your medical information. We may deny your request if we did not create the information you
want changed or for certain other reasons. If we deny your request, we will provide you with a written explanation.
You may respond with a written disagreement that will be added to the information you wanted changed. If we accept
your request to amend the information, we will make reasonable efforts to notify others, including people you name, of
the change and to include the changes in any future sharing of that information.
5. Receive a list of all the times we shared your medical information for purposes other than treatment, payment and
health care operations and other specified exceptions.
6. You have a right to receive a paper copy of Notice at any time.
If you have any questions about this Notice, or if you think that your privacy rights have been violated, please contact us.
You may also submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any
way if you choose to file a complaint.
Cathy Neilson, Privacy Officer (949) 759-3600