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Please feel free to download a printable copy of Our Privacy Practices.
Effective Date: April 27, 2009
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.
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have a right to adequate notice of the uses and disclosures of your protected health information ("PHI") (i.e., information that discloses your identity or leads to disclosure of your identity) that may be made by this medical practice. You are also entitled to notice of your rights and the duties of this practice with respect to your personal health information.
"WE RESPECT YOUR RIGHT TO PRIVACY AND UNDERSTAND THAT YOUR MEDICAL INFORMATION IS PERSONAL TO YOU. IN ORDER TO PROVIDE MEDICAL SERVICES TO YOU, WE CREATE RECORDS ABOUT YOUR HEALTH AND THE CARE WE PROVIDE. YOUR PERSONAL HEALTH INFORMATION IS CONFIDENTIAL AND THIS NOTICE IS INTENDED TO HELP YOU UNDERSTAND HOW OUR PRACTICE USES AND DISCLOSES YOUR PERSONAL HEALTH INFORMATION AND WHAT RIGHTS YOU HAVE WITH RESPECT TO YOUR MEDICAL INFORMATION."
REQUIRED BY LAW
Our practice has the following duties with respect to your personal health information:
- We are required by law to maintain the privacy of your personal health information.
- We must provide you with notice of our legal duties and privacy practices with respect to your personal health information.
- We must abide by the terms of the notice of privacy practices that is currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR INFORMATION
The following describes how our practice is permitted by law to share your personal health information with others in order to provide you with medical care. This notice does not describe every use or disclosure our practice makes; it is intended as a general overview.
MEDICAL TREATMENT. We may need to share information about you in order to provide medical care to you. For example, we may share information with other physicians, nurses or healthcare professionals entering information into your medical records relating to your medical care and treatment. We may share information about you including x-rays, prescriptions, and requests for lab work.
PAYMENT. We may need to disclose information about treatment, procedures or care our practice provided you in order to bill and receive payment for services we provided. We may share this information with you, an insurance company or any third party responsible for payment. We may need to disclose personal health information about you with your health plan and/or referring physician in order to obtain prior authorization for treatment, to determine whether payment for the treatment is covered by your plan or to facilitate payment of a referring physician.
WORKERS COMPENSATION. We may release medical information about you for work-related illness or injury for workers' compensation or other related programs.
HEALTH INSIGHT ACTIVITIES. Your personal health information may be disclosed to federal, state or local authorities as part of an investigation or government activity authorized by law. This may include audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary actions or other activities necessary for the oversight of the health care system, government benefit programs and compliance with government regulatory programs or civil rights laws.
LAW ENFORCEMENT. We may disclose your personal health information to law enforcement individuals if we are required to do so by law. We may disclose medical information about you in compliance with a court order, warrant or subpoena or summons issued by the court. We will make best efforts to contact you about these types of requests so that you can obtain an order restricting or prohibiting disclosure of the information requested. We may also use such information to defend ourselves in actions or threatened actions that may be brought against our practice.
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS. We may release personal health information to a coroner or medical examiner for the purposes of identification, determining cause of death or other duties as authorized by law. We may also release medical information to funeral directors as necessary to carry out their duties with respect to the deceased.
ORGAN, EYE, TISSUE DONATION. If you are an organ donor, we may disclose your personal health information to organ procurement organizations, or other entities that facilitate tissue donation or transplantation.
INMATES. If you are an inmate of a correctional institution or within the custody of law enforcement officials, we may disclose medical information about you to allow the institution to provide you with medical care, to protect the health and safety of yourself and others, or for the safety of the correctional institution.
Other uses and disclosures will be made only with your written authorization and you may revoke your authorization at any time.
Please note: if a use or disclosure for any purpose as described above is prohibited or materially limited by other applicable law (e.g., state law), the description of such use or disclosure must reflect the more stringent law.
You have the following rights with respect to your personal health information.
RIGHT TO RECEIVE PERSONAL HEALTH INFORMATION CONFIDENTIALLY. You have the right to receive confidential communications of your personal health information by alternate means or at alternate locations. For example, if you would like for us to communicate with you at home, and never at your workplace or send information to you on your workplace e-mail, you may request this of our practice. You must make this request in writing but do not need to disclose the reason for your request. We will attempt to accommodate all reasonable requests. Please be specific as to how or where you wish us to communicate with you.
CHANGES TO THIS NOTICE. Our practice is required to abide by the terms of this notice, which is currently in effect. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all personal health information we already have about you and may obtain in the future. If we change our notice, we will post notice of this change thirty (30) days prior to making the change effective. This change will be posted in the office waiting room. All revised notices will be promptly posted and made available to you in our waiting room. You may also request a current Notice when you visit our office. Changes to our notice will only be effective on the date that is reflected at the bottom of the last page on the revised Notice.
PRACTICE CONTACT. If you would like more information about this notice, please contact The Compliance Officer at (702) 737-7258. If you have any complaints regarding our privacy practices, please address your complaint to The Compliance Officer in writing and follow the designated complaint process below.
COMPLAINTS. If you believe your privacy rights may have been violated or you become aware of a privacy concern you would like to report to our practice, please follow this complaint process:
- 1. Send a written letter to the practice contact named above, including the following information:
- Name and Address
- Social Security Number or Patient Identification Number
- Detailed description of the circumstances surrounding your complaint, dates, times and any relevant information to help us understand your complaint.
- Contact Information
- Signature and Date
- Please allow twenty-one (21) business days for an answer from our practice regarding your complaint.
- If you are not satisfied with our response to your complaint, you may notify the Secretary of the Department of Health & Human Services.
U.S. Department of Health & Human Resources
907 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310 (415) 437-8311 (TDD)
(415) 437-8329 FAX
ADDITIONAL PRIVACY PROTECTIONS. Our practice is committed to protecting your privacy and the proper use and disclosures of your personal health information. For example, if we treat patients with particularly sensitive conditions, even though the law allows us to disclose the information for various reasons, we will not do so unless required by law.
Date of Last Revision: April 27, 2009
Effective Date: Immediately