Form PF-1000 NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective April 14, 2003
This Notice of Privacy Practices is being provided to you
as a requirement of the privacy regulations issued under the
Health Insurance Portability and Accountability Act of 1996
(HIPAA). This notice describes under what circumstances our
medical practice (the Practice") may use and disclose
medical information about you to carry out treatment, payment
or health care operations and for other purposes that are
permitted or required by law. It also describes your rights
to access and control medical information about you. Your
medical information (i.e., "protected health information"
for purposes of HIPAA) is information about you, including
demographic information, that may identify you and that relates
to your past, present or future physical or mental health
or condition. We are required by law to maintain the privacy
of your medical information and we must abide by the terms
of this notice.
In this notice we provide descriptions of the different ways
that we may use and disclose your medical information. In
some cases, an example is provided to describe the types of
uses and disclosures of your medical information that may
be made by us.
In addition to the privacy protections provided under federal
law (which are described in more detail below), and except
in certain limited circumstances, California law requires
us to obtain your written consent (or, under some statutes
or rules, written consent from your attorney, guardian, or
upon court order) before we can use or disclose your information
if you qualify as a patient that:
Suffers from a sexually transmitted disease;
Is HIV+ or has Acquired Immune Deficiency Syndrome
Suffers from a mental disorder;
Has a problem with substance abuse;
Is eligible to receive benefits for the State of California
for certain developmental disabilities or mental retardation;
Receives rehabilitative services through the California Medi-Cal
program;
Is eligible to receive certain other benefits through California's
Medi-Cal program
Uses and Disclosures of Protected
Health Information
For Treatment. We may use
medical information about you to provide you with medical
treatment or services. We may disclose medical information
about you to doctors, nurses, technicians, residents, or other
health care professionals who are involved in taking care
of you. For example, we may disclose your medical information
to another doctor or healthcare provider (such as a specialist,
your primary care doctor, a pharmacist or clinical laboratory)
who, at the direction of your doctor, is involved in your
treatment or care. California Law may also limit these uses
or disclosures of your medical information.
For Payment. We may use and
disclose medical information about you so that the treatment
and services you receive may be billed to and payment may
be collected from you, an insurance company or others. For
example, your insurance company may need to know certain information
about the diagnostic test (such as a stress test or electrocardiogram)
or procedure (such as a sigmoidoscopy or conization) you received
so they will pay us or reimburse you for the test or procedure.
We may also use and disclose medical information about you
to obtain prior approval or to determine whether your insurance
company will cover a proposed treatment. California Law may
also limit these uses or disclosures of your medical information.
For Health Care Operations.
We may use and disclose medical information about you, for
health care operations. This is necessary to make sure that
all or our patients receive quality care and to support the
business operations of our Practices. These uses or disclosures
of your medical information may also be limited by California
Law.
A few examples of our health care operations are quality improvement,
doctor/employee review activities, compliance, and the training
of health care professionals. Also included in healthcare
operations are the day-to-day tasks that are required to keep
our Practice locations functioning and to provide you with
quality care.
For example, in the waiting room when your doctor is ready
to see you. In addition, we may contact you (e.g., by telephone
or mail) to remind you about an appointment, to provide instructions
prior to a diagnostic test or procedure, to provide information
about treatment alternatives, or other health-related benefits
that may be of interest to you, or to discuss your account.
In such cases, we may leave a message on your answering machine,
if available. The departments that may have reason to communicate
with you regarding your care include the following:
As another part of health care operations, we may use and
disclose medical information about you to our "business
associates". Our business associates, such as transcription
services, collection agency, and call answering service, just
to name a few, perform services on behalf of the Practice.
Whenever an arrangement between our Practices and a business
associate involves the use or disclosure of medical information
about you, we will have a written contract with that business
associate that will require such business associate to agree
to protect the privacy of your medical information.
Uses and Disclosures of Protected Health
Information Not Discussed in This Notice
Uses and disclosures of your medical information that have
not been described in this notice will not be made without
your written permission. If you provide us permission to use
or disclose medical information about you, you may revoke
that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose medical information
about you for the reasons covered by such permission. However,
you should understand that we are unable to take back any
actions we have already taken with your permission, and that
we are required to retain our records of the care we provided
to you.
Other Permitted and Required
Uses and Disclosures That May Be Made With Your Agreement
or Opportunity to Object
You have the opportunity to agree or object to the use or
disclosure of all or parts of medical information about you
in the situations discussed in the following paragraph. If
you are not present or able to agree or object to the use
or disclosure of your medical information in such instances,
then your doctor may, using his or her professional judgment,
use or disclose your medical information if believed to be
in your best interest. California Law may also limit these
uses or disclosures of your medical information.
Individuals Involved in Your Care
or Payment for Your Care. Unless you object, in an
urgent situation we may release medical information about
you to a friend, family member, or any other person you identify
who is involved in your medical care. We may also give information
to someone who helps pay for your care. We may use or disclose
medical information about you to notify or assist in notifying
a family member, personal representative or any other person
that is responsible for your care of your location, general
condition or death. In addition, we may disclose medical information
about you to an entity assisting in a disaster relief effort
so that your family can be notified about your location, general
condition or death.
Research
We may use and disclose medical information about you for
research purposes under certain circumstances. However, other
than obtaining medical information in preparation for a research
program or protocol, your specific permission is generally
required if such research will involve the use or disclosure
of your medical information.
Other Permitted and Required Uses and
Disclosures That May Be Made Without Your Authorization or
Opportunity to Agree or Object
Unless California Law requires otherwise, we may use or disclose
your protected health information in certain situations without
your specific permission or without giving you an opportunity
to agree or object. Among these situations are the following:,
Required By Law. We are permitted
to disclose medical information about you when required to
do so by federal, state or local law.
To Avert a Serious Threat to Health
or Safety. In certain circumstances, we may use and
disclose medical information about you when necessary to prevent
a serious threat to your health and safety or the health and
safety of the public or another person.
To Notify an Employer of Medical
Information Related to an Employee:
or to evaluate whether an employee has a work-related
injury or illness,
the use or disclosure of information is related to these
purposes,
the use and disclosure is required for the employer to
comply with its legal obligations,
and the covered entity was providing services at the
request of an employer for medical surveillance the
employee is given notice that the information will be
disclosed (notice can be handed
Military and Veterans. If
you are a member of the armed forces, in certain circumstances
we may release information about you to an appropriate government
body.
Workers' Compensation. We
may release medical information about you to comply with workers'
compensation (or similar) laws.
Inmates. If you are an inmate
of a correctional institution or under the custody of a law
enforcement official, we may in certain circumstances release
medical information about you to the correctional institution
or law enforcement official. .
Public Health Activities.
We may disclose medical information about you for public health
activities. These activities generally include, without limitation,
the following:
to prevent or control disease, injury or disability;
to report births and deaths;
to report child abuse and neglect;
to report animal bites;
to report reactions to medications or problems with products;
to notify people of recalls or products they may be using;
to notify a person who may have been exposed to a disease
or may be at risk for contracting or spreading disease
or condition, or
to notify the appropriate government authority if we
believe a patient has been the victim of abuse, neglect
or
domestic violence
Health Oversight Activities.
We may disclose medical information to a health oversight
agency for activities related to the monitoring of the health
care system, government programs or compliance with civil
rights laws. These oversight activities include; for example,
audits, investigations, inspections, and licensure.
Lawsuits and Disputes. In
certain circumstances, we may disclose medical information
about you in response to a subpoena, discovery request, or
other lawful order from a court.
Law Enforcement. We may release medical information if asked
to do so by a law enforcement official as part of law enforcement
activities in certain circumstances.
Coroners, Medical Examiners and
Funeral Directors. If authorized by law, we may release
medical information to a coroner or medical examiner. We may
also release medical information to a funeral director, as
consistent with applicable law, in order to permit the funeral
director to carry out his or her duties. Also, medical information
may be used and disclosed for organ, or tissue donation purposes.
Protective Services for the President,
National Security and Intelligence Activities. We may
disclose medical information about you to authorized federal
officials so they may, without limitation, (i) provide protection
to the President; other authorized persons or foreign heads
of state or conduct special investigations, or (ii) conduct
lawful intelligence, counter-intelligence, or other national
security activities authorized by law.
Your Rights Regarding: Medical Information
We Maintain About You
Right to Inspect and Copy.
You have the right to inspect and copy medical information
that relates to you. To do so, you must submit your request
in writing to our Privacy Officer at the address below. If
you request a copy of the information, we may charge you a
reasonable fee for the costs of copying, mailing or other
supplies associated with your request.
We may deny your request to inspect and copy in certain circumstances.
If you are denied access to medical information, you may in
certain circumstances request that the denial be reviewed.
In such cases, another licensed health care professional chosen
by ProHealth/Argus will review your request and the denial.
The person conducting the review will not be the person who
denied your request. We will comply with the outcome of the
review.
Right to Amend. If you feel
that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. In certain
circumstances, you have the right to amend your medical information..
Your request for an amendment must be made in writing and
submitted to our Privacy Officer at the address below. In
addition, you must provide a reason that supports your request.
We may deny your request for an amendment in certain circumstances.
Right to an Accounting of Disclosures.
You have the right to receive an accounting of certain disclosures
that we have made. To request an accounting of disclosures,
you must submit your request in writing to our Privacy Officer
at the address below. Your request must state a time period
that may not be longer than six (6) years and may not include
dates before April 14, 2003. Your request should indicate
in what form you want the list (for example, on paper or electronically).
The first list you request within a 12-month period will be
free. For additional lists within a single 12-month period,
we may charge you for the costs of providing the list. We
will notify you of the cost involved and you may choose to
withdraw or modify your request at that time before any costs
are incurred.
Right to Request Restrictions.
You have the right to request a restriction or limitation
on how we use or disclose certain medical information about
you, including how we use or disclose your medical information
for treatment, payment or health care operations.
To request restrictions, you must make your request in writing
to our Privacy Officer at the address below. In your request,
you must tell us: 1) what information you want to limit; 2)
whether you want to limit our use, disclosure or both; and
3) to whom you want the limits to apply.
We are not required to agree to your request. If we do agree,
we will comply with your request unless the information is
needed to provide you emergency treatment.
Right to Request Confidential Communications. You have the
right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example,
you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your
request in writing to our Privacy Officer at the address below.
We will not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how or
where you wish to be contacted.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice at any time.
Even if you have agreed to receive this notice electronically,
you are still entitled to a paper copy of this notice. To
obtain a paper copy of this notice, you can request one in
writing from our Privacy Officer at the address below or simply
ask for a copy at the reception/check-in desk at your doctor's
office.
Changes to his Notice
We reserve the right to change this notice at any time.
We reserve the right to make the revised or changed notice
effective for medical information we already have about you
as well as any information we receive in the future. We will
post a copy of the current notice. The notice will contain
on the first page, in the bottom right-hand comer, the effective
date.
Complaints
If you believe your privacy rights have been violated, you
may file a complaint with us or with the Secretary of the
Department of Health and Human Services. To file a complaint,
contact our Privacy Officer at the address below. All complaints
must be submitted in writing. You will not be penalized for
filing a complaint, and we will seek to deal with all complaints
in a reasonable and efficient manner.
Privacy Officer:
Linda Grow, HIPAA Compliance Officer
ProHealth Partners/Argus Medical Management
1045 Atlantic Avenue, Suite 705 . Long Beach, California 90813
(562) 491-9274 . Fax No. (562) 491-9671 Email lgrow@medicity.com
Form PF-2000
Acknowledgement of Receipt of Notice of Privacy Practices The Practice reserves the right to modify the
privacy practices outlined in this notice.
I have received a copy of the Notice of
Privacy Practices.
_____________________________________________________________
Name of patient (Print or Type)
______________________________________________________________
Signature of Patient
______________________________________________________________
Date
______________________________________________________________
Signature of Patient Representative
(Required if patient is a minor or an adult who is unable
to sign this form)
_______________________________________________________________
Relationship of Representative
Documentation of Attempt to Obtain
Acknowledgement of Receipt of Privacy Practices
An attempt was made to obtain an acknowledgement of the Notice
of Privacy Practices on
______________________. The acknowledgement was not obtained
because:
