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Notice of Privacy Practices
for Protected Health Information
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!
With your consent, the practice is permitted
by federal privacy laws to make uses and disclosures of your health information
for purposes of treatment, payment, and health care operations. Protected health
information is the information we create and obtain in providing our services to
you. Such information may include documenting your symptoms, examination and
test results, diagnoses, treatment, and applying for future care or treatment.
It also includes billing documents for those services.
Example of uses of your health
information for treatment purposes:
A nurse obtains treatment information about you and records it in a health
record. During the course of your treatment, the doctor determines a need to
consult with another specialist in the area. The doctor will share the
information with such specialist and obtain input.
Example of use of your health
information for payment purposes:
We submit a request for payment to your health insurance company. The health
insurance company requests information from us regarding medical care given. We
will provide information to them about you and the care given.
Example of Use of Your Information
for Health Care Operations:
We obtain services from our insurers or other business associates such as
quality assessment, quality improvement, outcome evaluation, protocol and
clinical guidelines development, training programs, credentialing, medical
review, legal services, and insurance. We will share information about you with
such insurers or other business associates as necessary to obtain these
services.
Your Health Information Rights
The health record we maintain and billing records are the physical property of
the practice. The information in it, however, belongs to you. You have a right
to:
• Request a restriction on certain uses and disclosures of your health
information by delivering the request in writing to our office. We are not
required to grant the request but we will comply with any request granted;
• Request that you be allowed to inspect and copy your health record and billing
record—you may exercise this right by delivering the request in writing to our
office;
• Appeal a denial of access to your protected health information except in
certain circumstances;
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require that
the request for amendment and any denial be attached in all future disclosures
of your protected health information;
• Obtain an accounting of disclosures of your health information as required to
be maintained by law by delivering a written request to our office. An
accounting will not include internal uses of information for treatment, payment,
or operations, disclosures made to you or made at your request, or disclosures
made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alternative
means or at an alternative location by delivering the request in writing to our
office; and,
• Revoke authorizations that you made previously to use or disclose information
except to the extent information or action has already been taken by delivering
a written revocation to our office.
If you want to exercise any of the above
rights, please contact Ms. Kelley Morse at (925) 830-0800 or, in person or in
writing, during normal hours at
5401 Norris Canyon Road, Suite 210,
San Ramon,
CA
94583
. She will provide you with assistance on the
steps to take to exercise your rights.
Our Responsibilities
The practice is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the
information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health
information with you.
We reserve the right to amend, change, or
eliminate provisions in our privacy practices and access practices and to enact
new provisions regarding the protected health information we maintain. If our
information practices change, we will amend our Notice. You are entitled to
receive a revised copy of the Notice by calling and requesting a copy of our
"Notice" or by visiting our office and picking up a copy.
To Request Information or File a
Complaint
If you have questions, would like additional information, or want to report a
problem regarding the handling of your information, you may contact Ms. Theresa
via telephone at (925) 830-0800.
Additionally, if you believe your privacy
rights have been violated, you may file a written complaint at our office by
delivering the written complaint to Ms. Theresa. You may also file a written
complaint by mailing it to the Secretary of Health and Human Services at Federal
Office Building, 50 United Nations Plaza, San Francisco, CA 94102.
• We cannot, and will not, require you to
waive the right to file a complaint with the Secretary of Health and Human
Services (HHS) as a condition of receiving treatment from the practice.
• We cannot, and will not, retaliate against you for filing a complaint with the
Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to
notify, or assist in notifying, a family member, personal representative, or
other person responsible for your care, about your location, and about your
general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative,
close personal friend, or any other person you identify, health information
relevant to that person's involvement in your care or in payment for such care
if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse
events with respect to products and product defects, or post-marketing
surveillance information to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose
your protected health information to the extent necessary to comply with laws
relating to Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease,
injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as
allowed by law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the
institution, or its agents, your protected health information necessary for your
health and the health and safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes
as required by law, such as when required by a court order, or in cases
involving felony prosecutions, or to the extent an individual is in the custody
of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to
appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial
or administrative proceeding as allowed or required by law, with your consent,
or as directed by a proper court order.
Other Uses
Other uses and disclosures besides those identified in this Notice will be made
only as otherwise authorized by law or with your written authorization and you
may revoke the authorization as previously provided.
Website
If we maintain a website that provides information about our entity, this Notice
will be on the website.
Effective Date:
April 14, 2003
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