| NOTICE
OF PRIVACY PRACTICES
THIS NOTICE
DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT
TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to
maintain the privacy of your health information. We are
also required to give you this Notice about our privacy
practices, our legal duties, and your rights concerning
your health information. We must follow the privacy practices
that are described in this Notice while it is in effect.
This Notice takes effect (April 14, 2003), and will remain
in effect until we replace it.
We reserve the right to change our privacy practices and
the terms of this Notice at any time, provided such changes
are permitted by applicable law. We reserve the right
to make the changes in our privacy practices and the new
terms of our Notice effective for all health information
that we maintain, including health information we created
or received before we made the changes. Before we make
a significant change in our privacy practices, we will
change this Notice and make the new Notice available upon
request.
You may request a copy of our Notice at any time. For
more information about our privacy practices, or for additional
copies of this Notice, please contact us using the information
listed at the end of this Notice.
USES AND DISCLOSURES
OF HEALTH INFORMATION
We use and disclose health information about you for treatment,
payment, and healthcare operations. For example:
Treatment:
We may use or disclose your health information to a physician
or other healthcare provider providing treatment to you.
Payment: We may use and disclose
your health information to obtain payment for services
we provide to you.
Healthcare Operations:
We may use and disclose your health information in connection
with our healthcare operations. Healthcare operations
include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your
Authorization: In addition to our use of your
health information for treatment, payment or healthcare
operations, you may give us written authorization to use
your health information or to disclose it to anyone for
any purpose. If you give us an authorization, you may
revoke it in writing at any time. Your revocation will
not affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for
any reason except those described in this Notice.
To Your Family and Friends: We must disclose
your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health
information to a family member, friend or other person
to the extent necessary to help with your healthcare or
with payment for your healthcare, but only if you agree
that we may do so.
Persons Involved In Care:
We may use or disclose health information to notify, or
assist in the notification of (including identifying or
locating) a family member, your personal representative
or another person responsible for your care, of your location,
your general condition, or death. If you are present,
then prior to use or disclosure of your health information,
we will provide you with an opportunity to object to such
uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health information
based on a determination using our professional judgment
disclosing only health information that is directly relevant
to the person’s involvement in your healthcare.
We will also use our professional judgment and our experience
with common practice to make reasonable inferences of
your best interest in allowing a person to pick up filled
prescriptions, medical supplies, x-rays, or other similar
forms of health information.
Marketing Health-Related
Services: We will not use your health information
for marketing communications without your written authorization.
Required by Law: We may use or disclose
your health information when we are required to do so
by law.
Abuse or Neglect: We may
disclose your health information to appropriate authorities
if we reasonably believe that you are a possible victim
of abuse, neglect, or domestic violence or the possible
victim of other crimes. We may disclose your health information
to the extent necessary to avert a serious threat to your
health or safety or the health or safety of others.
National Security: We may disclose to
military authorities the health information of Armed Forces
personnel under certain circumstances. We may disclose
to authorized federal officials health information required
for lawful intelligence, counterintelligence, and other
national security activities. We may disclose to correctional
institution or law enforcement official having lawful
custody of protected health information of inmate or patient
under certain circumstances.
Appointment Reminders:
We may use or disclose your health information to provide
you with appointment reminders (such as voicemail messages,
postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at
or get copies of your health information, with limited
exceptions. You may request that we provide copies in
a format other than photocopies. We will use the format
you request unless we cannot practicably do so. (You must
make a request in writing to obtain access to your health
information. You may obtain a form to request access by
using the contact information listed at the end of this
Notice. We will charge you a reasonable cost-based fee
for expenses such as copies and staff time. You may also
request access by sending us a letter to the address at
the end of this Notice. If you request copies, we will
charge you $0.25 for each page, $40.00 per hour for staff
time to locate and copy your health information, and postage
if you want the copies mailed to you. If you request an
alternative format, we will charge a cost-based fee for
providing your health information in that format. If you
prefer, we will prepare a summary or an explanation of
your health information for a fee. Contact us using the
information listed at the end of this Notice for a full
explanation of our fee structure.)
Disclosure
Accounting: You have the right to receive a list
of instances in which we or our business associates disclosed
your health information for purposes, other than treatment,
payment, healthcare operations and certain other activities,
for the last 6 years, but not before April 14, 2003. If
you request this accounting more than once in a 12-month
period, we may charge you a reasonable, cost-based fee
for responding to these additional requests.
Restriction:
You have the right to request that we place additional
restrictions on our use or disclosure of your health information.
We are not required to agree to these additional restrictions,
but if we do, we will abide by our agreement (except in
an emergency).
Alternative Communication:
You have the right to request that we communicate
with you about your health information by alternative
means or to alternative locations. {You must make your
request in writing.} Your request must specify the alternative
means or location, and provide satisfactory explanation
how payments will be handled under the alternative means
or location you request.
Amendment: You
have the right to request that we amend your health information.
(Your request must be in writing, and it must explain
why the information should be amended.) We may deny your
request under certain circumstances.
Electronic
Notice: If you receive this Notice on our Web
site or by electronic mail (e-mail), you are entitled
to receive this Notice in written form.
QUESTIONS
AND COMPLAINTS
If you want more information about our privacy practices
or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy
rights, or you disagree with a decision we made about
access to your health information or in response to a
request you made to amend or restrict the use or disclosure
of your health information or to have us communicate with
you by alternative means or at alternative locations,
you may complain to us using the contact information listed
at the end of this Notice. You also may submit a written
complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file your complaint
with the U.S. Department of Health and Human Services
upon request.
We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file
a complaint with us or with the U.S. Department of Health
and Human Services.
Contact Officer: Kelly Van Meter Latini
Telephone: 714) 379-8585
Fax: (714) 379-8909
E-mail: kelly@privatemds.com
Address: 7677 Center Dr., Suite 300; Huntington Beach,
CA., 92647 This Form is educational
only, does not constitute legal advice,
and covers only federal, not state, law.
(August 14, 2002).
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