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Notice
of Privacy Practices This notice is to inform
you of our privacy practices and how we maintain the confidentiality of
your “protected health information” (PHI).
We understand that this information is personal and completely
confidential so this policy is designed to explain to you how we handle
your information.
Your confidentiality is maintained by
restricting access only to employees who need access to your PHI in order
to process services. Also we have
implemented appropriate physical, electronic and procedural safeguards
to protect your PHI against any unauthorized use or disclosure. Our staff is required to complete and annually
review a training program designed to protect your PHI.
Although there are many safeguards to
protect your PHI, there are some instances where Federal and State laws
allow us to use/disclose your information without your consent. These are:
1.
To provide your
health care services
2.
To bill and collect
payments for the health care services provided
3.
To provide you
with treatment alternatives
4.
To inform you
about health benefits and services
5.
To remind you
about your appointments
6.
To complete health
care operations such as to resolve an appeal or grievance
7.
When required
by law
8.
For public health
activities
9.
For reports about
child and other types of abuse or neglect or domestic violence
10.
For health oversight
activities
11.
For lawsuits
and other legal disputes
12.
For law enforcement
purposes
13.
To report to
coroners, medical examiners, or funeral directors
14.
For tissue or
organ donations
15.
For research
16.
To avert a serious
threat to the health or safety of you or others
17.
For national
security and intelligence/military activities
18.
In connection
with services provided under worker’s compensation laws
19.
To family members
or other persons who are involved in your care or payment of care
20.
To create a directory
that includes your name, your location at the facility, your general condition
and your religious preference when you are in an affiliated hospital
You may agree or object to this disclosure.
If you cannot agree or object because you are incapacitated or otherwise
unavailable, we will use our professional judgment.
If you are a parent, you may control your
minor child’s PHI. There are some cases where we are permitted or even
required by law to deny your access to your child’s PHI, such as when
your child can legally consent to medical services without your permission.
There are some types of PHI, such as HIV
test results or mental health information, which are protected by stricter
laws. However, even this PHI may be used or disclosed without your written
authorization if required or permitted by law.
All other uses and disclosures of your
PHI require your written authorization.
If you need an authorization form, we
will send you one for you or your personal representative to complete.
When you receive the form, please fill it out and send it to the address
below:
You may revoke or modify your authorization
at any time by writing to us at the same address. Please note that your
revocation or modification may not be effective in some circumstances,
such as when we have already taken action relying on your authorization.
You also have the right to review and
copy any of your PHI that we possess. If you wish to see your PHI, please
write to us and we will tell you when and where you can review your PHI
in our possession within our normal business hours. If you would like
a copy of the information we have, please write to us at the same address.
If we provide you with a copy, we may charge a reasonable administrative
fee for copying your PHI to the extent permitted by applicable law. If
we deny your request for review or copy of your PHI, we will explain the
reason in writing. If we do not have your PHI, but know who does, we will
tell you whom to contact. If you wish to have your PHI corrected or updated,
please write to us and tell us what you want changed and why. We will
respond to you in writing, either accepting or denying your request. If
we deny your request, we will explain why. You may also send us an addendum
that is no longer than 250 words in length for each item you believe is
incorrect. Please clearly indicate that you want the addendum to be included
in your PHI. We will attach your addendum to the record(s) of your PHI.
Your amended PHI will be available for your review upon request.
You have the right to request an accounting
of certain disclosures that we make of your PHI by writing to us. Please
note that certain disclosures, such as those made for treatment, payment,
or health care operations, need not be included in the accounting we provide
to you. We will respond to your request within a reasonable period of
time, but no later than 60 days after we receive your written request.
You have the right to request and receive
a paper copy of this Notice.
You have the right to request restrictions
on how we use and disclose your PHI for our treatment, payment, and health
care operations. All requests must be made in writing. Upon receipt, we
will review your request and notify you whether we have accepted or denied
your request. Please note that we are not required to accept your request
for restrictions. Your PHI is critical for providing you with quality
health care. We believe we have taken appropriate safeguards and internal
restrictions to protect your PHI, and that additional restrictions may
be harmful to your care.
You have the right to request that we
provide your PHI to you in a confidential manner. For example, you may
request that we send your PHI by an alternate means (e.g., sending by
a sealed envelope, rather than a post card) or to an alternate address
(e.g., calling you at a different telephone number, or sending a letter
to you at your office address rather than your home address). We will
accommodate any reasonable requests, unless they are administratively
too burdensome, or prohibited by law.
We must follow the privacy practices set
forth in this Notice while in effect. If you have any questions about
this Notice, wish to exercise your rights, or file a complaint; please
direct your inquiries to the address below:
You may contact your Health Plan or the
California Department of Managed Care with your concerns as well. You
also have the right to directly complain to the Secretary of the United
States Department of Health and Human Service. We will not retaliate against
you for filing a complaint against us.
We will use and disclose your PHI to the
fullest extent authorized by law. We reserve the rights as expressed in
this Notice. We reserve the right to revise our privacy practices consistent
with the law and make them applicable to your entire PHI we possess, regardless
of when it was received or created. If we make material or important changes
to our privacy practices, we will promptly revise our Notice. Unless law
requires the changes, we will not implement material changes to our privacy
practices before we revise our Notice. You may request updates to this
Notice at any time.
This Notice is effective: April 14, 2003
Attn: Privacy
Officer Memorial Sports
& Internal Medicine 10861 Cherry
Street #105 Los Alamitos,
CA 90720 (562) 795-6406
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