THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
This practice is committed to maintaining the privacy of your Protected Health Information (PHI), which includes information about your health condition and the care and treatment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.
The practice may use and/or disclose your PHI provided that it first obtains a valid Consent signed by you. The Consent will allow the Practice to use and/or disclose your PHI for the purposes of:
- Treatment – In order to provide you with the health care you require, the Practice will provide your PHI to those health care professionals, whether on the Practice’s staff or not, directly involved in your care so that they may understand your health condition and needs. For example, a physician treating you for kidney problems may need to know the results of your latest physical examination by this office.
- Payment – In order to get paid for services provided to you, the Practice will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, the Practice may need to tell your insurance plan about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.
- Health Care Operations – In order for the Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose you PHI. For example, the Practice may use your PHI in order to evaluate the performance of the Practice’s personnel in providing care to you.
NO CONSENT REQUIRED
The practice may use and/or disclose your PHI, without a written Consent from you, in the following instances:
- De-identified Information – Information that does not identify you and, even without your name, cannot be used to identify you.
- Business Associate – To a business associate if the Practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.
- Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
- Emergency Situations – For the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible; or to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.
- Communication Barriers – If, due to substantial communication barriers or inability to communicate, the Practice has been unable to obtain your Consent and the Practice determines, in the exercise of its professional judgment, that your Consent to receive treatment is clearly inferred from the circumstances.
- Public Health Activities – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease.
- Abuse, Neglect or Domestic Violence – To a government authority if the Practice is required by law to make such disclosure. If the Practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.
- Health Oversight Activities – Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community’s health care system.
You have the right to:
- Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you must submit a written request to the Practice’s Privacy Officer. Please allow a reasonable processing time for the change in our procedure to be completed.
- Request restrictions on certain use and/or disclosure of you PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice’s Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request (within 60 days) unless the information is needed in order to provide you with emergency treatment.
- Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice’s Privacy Officer. The Practice will accommodate all reasonable requests.
- Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to the Practice’s Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are defined by law, the Practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.
- Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Practice’s Privacy Officer. The Practice has 60 days to notify you acceptance or refusal to amend. You must provide a reason that supports your request. The Practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice’s denial, you will have the right to submit a written statement of disagreement.
- Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to the Practice’s Privacy Officer. Practice will act on the request for an account of disclosure within 60 days. The request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12-month period will be free, but the Practice may charge you for the cost of providing additional lists. The Practice will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
- Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice’s Privacy Officer.
- Complain to the Practice or the Secretary of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice’s Privacy Officer. All complaints must be in writing.
- To obtain more information on, or have your questions about your rights answered, you may contact the Practice’s Privacy Officer, Dr. Hans Freericks at (510) 797-4796 or via fax at (510) 797-8700.
- Is required to abide by the terms of this Privacy Notice.
- Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice Provisions effective for all of your PHI that it maintains.
- Will distribute any revised Privacy Notice to you prior to implementation.
- Will not retaliate against you for filing a complaint.
- Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.
- Is required by State law to maintain a higher level of confidentiality with respect to certain portions of your medical information that is provided for under federal law. In particular, the Practice is required to comply with the following State statutes:
This Notice is in effect as of 4/14/03. This notice, and any alterations or amendments made hereto, will expire seven years after the date upon which the record was created.