LA
(323)
232-1234
|
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.
respects your privacy. We understand that your
personal health information is very sensitive. We will not disclose your
information to others unless you tell us to do so, or unless the law authorizes
or requires us to do so.
The law protects the privacy of the health information we
create and obtain in providing our care and services to you. For example, your
protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and
billing and payment information relating to these services. Federal and state
law allows us to use and disclose your protected health information for
purposes of treatment and health care operations. State law requires us to get
your authorization to disclose this information for payment purposes.
Examples of Use and Disclosures of
Protected Health Information for Treatment, Payment, and Health Operations
For treatment:
·
Information obtained by a nurse,
physician, or other member of our health care team will be recorded in your
medical record and used to help decide what care may be right for you.
·
We may also provide information to others
providing you care. This will help them stay informed about your care.
For payment:
·
We request payment from your health
insurance plan. Health plans need information from us about your medical care.
Information provided to health plans may include your diagnoses,
procedures performed, or recommended care.
For health care operations:
·
We use your medical records to assess
quality and improve services.
·
We may use and disclose medical records to
review the qualifications and performance of our health care providers and to
train our staff.
·
We may contact you to remind you about
appointments and give you information about treatment alternatives or other
health-related benefits and services.
·
We may contact you to raise funds.
·
We may use and disclose your information
to conduct or arrange for services, including:
·
medical quality review by your health
plan;
·
accounting, legal, risk management, and
insurance services;
·
audit functions, including
fraud and abuse detection and compliance programs.
Your Health Information Rights
The health and billing records we create
and store are the property of . The protected health
information in it, however, generally belongs to you. You have a right to:
·
Receive, read, and ask questions about
this Notice;
·
Ask us to restrict certain uses and
disclosures. You must deliver this request in writing to us. We are not
required to grant the request. But we will comply with any request granted;
·
Request and receive from us a paper copy
of the most current Notice of Privacy Practices for Protected Health
Information (“Notice”);
·
Request that you be allowed to see and get
a copy of your protected health information. You may make this request in
writing. We have a form available for this type of request.
·
Have us review a denial of access to your
health information—except in certain circumstances;
·
Ask us to change your health information.
You may give us this request in writing. You may write a statement of
disagreement if your request is denied. It will be stored in your medical
record, and included with any release of your records.
·
When you request, we will give you a list
of disclosures of your health information. The list will not include
disclosures to third-party payors. You may receive
this information without charge once every 12 months. We will notify you of the
cost involved if you request this information more than once in 12 months.
·
Ask that your health information be given
to you by another means or at another location. Please sign, date, and give us
your request in writing.
·
Cancel prior authorizations to use or
disclose health information by giving us a written revocation. Your revocation
does not affect information that has already been released. It also does not
affect any action taken before we have it. Sometimes, you cannot cancel an
authorization if its purpose was to obtain insurance.
For help with these rights during normal
business hours, please contact:
LA
(323)
232-1234
Our Responsibilities
We are required to:
· Keep
your protected health information private;
· Give
you this Notice;
·
Follow the terms of this Notice.
We have the right to change our practices
regarding the protected health information we maintain. If we make changes, we will update this
Notice. You may receive the most recent
copy of this Notice by calling and asking for it or by visiting our to pick one up.
To Ask for Help or Complain
If you have questions, want more information, or want to
report a problem about the handling of your protected health information, you
may contact:
If you believe your privacy rights have been violated, you
may discuss your concerns with any staff member. You may also deliver a written complaint to at our . You may also file a complaint with the U.S.
Secretary of Health and Human Services.
We respect your right to file a complaint
with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate
against you.
Other Disclosures and Uses of
Protected Health Information
Notification
of Family and Others
·
Unless you object, we may release health
information about you to a friend or family member who is involved in your
medical care. We may also give information to someone who helps pay for your
care. We may tell your family or friends your condition and that you are in a
hospital. In addition, we may disclose health information about you to assist
in disaster relief efforts.
You have the right to object to this use
or disclosure of your information. If
you object, we will not use or disclose it.
We may use and disclose your
protected health information without your authorization as follows:
·
With Medical Researchers—if the research has
been approved and has policies to protect the privacy of your health
information. We may also share
information with medical researchers preparing to conduct a research project.
·
To Funeral Directors/Coroners consistent with
applicable law to allow them to carry out their duties.
·
To Organ Procurement Organizations
(tissue donation and transplant) or persons who obtain, store, or
transplant organs.
·
To the Food and Drug Administration
(FDA) relating to problems with food, supplements, and products.
·
To Comply With
Workers’ Compensation Laws—if you make a workers’ compensation
claim.
·
For Public Health and Safety
Purposes as Allowed or Required by Law:
—
to prevent or reduce a serious, immediate
threat to the health or safety of a person
—
or the public.
—
to public health or legal authorities
·
to protect public health and safety
·
to prevent or control disease, injury, or
disability
·
to report vital statistics
such as births or deaths.
·
To Report Suspected Abuse or
Neglect to public authorities.
·
To Correctional Institutions if you are in jail or
prison, as necessary for your health and the health and safety of others.
·
For Law Enforcement Purposes such as when we receive
a subpoena, court order, or other legal process, or you are the victim of a
crime.
·
For Health and Safety Oversight
Activities. For example, we may share health information with the
Department of Health.
·
For Disaster Relief Purposes. For example, we may
share health information with disaster relief agencies to assist in
notification of your condition to family or others.
·
For Work-Related Conditions That
Could Affect Employee Health. For example, an employer may ask us to
assess health risks on a job site.
·
To the Military Authorities of
·
In the Course of
Judicial/Administrative Proceedings at your request, or as directed by a
subpoena or court order.
·
For Specialized Government
Functions. For example, we may share information for national
security purposes.
Other Uses and Disclosures of
Protected Health Information
·
Uses and disclosures not in this Notice
will be made only as allowed or required by law or with your written
authorization.
Web Site
·
We have a Web site that provides
information about us. For your benefit, this Notice is on the Web site at this
address:
.
Effective Date: September 2006