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.
- Below is a description, including at least one (1) example, of the types of uses and disclosures that the above organization is permitted to make for each of the following purposes: treatment, payment and health care operations.
Disclosures to other health care providers, including, for example, to patients' attending physicians. Submission of claims and supporting documentation including, for example, to organizations responsible to pay for services provided by the organization.
Disclosures to conduct the operations of the organization, including, for example, sharing information to supervisors of staff members who provide care to patients.
- Below is a description of each of the other purposes for which the organization is permitted or required to use or disclose protected health information without an individual's written consent or authorization.
To patients, incident to another permitted use or disclosure, by agreement, to the Secretary of the U.S. Department of Health and Human Services, as required by law, for public health activities, information about victims of abuse, neglect or domestic violence, health oversight activities, for judicial and administrative proceedings, for law enforcement proceedings, about decedents, for cadaveric organ, eye or tissue donation, for research purposes, to avert a serious threat to health or safety, for specific government functions, to business associates of the organization, to personal representatives, de-identified information, to workforce members who are victims of crimes, to workers' compensation programs, for involvement in the individual's care and for notification purposes, with the individual present, for limited uses and disclosures when the individual is not present, and for disaster relief purposes.
- Other uses and disclosures, such as disclosure of psychotherapy notes, use of protected health information for marketing activities and the sale of protected health information, will be made only with the individual's written authorization and the individual may revoke such authorization.
- The organization may contact the individual to schedule visits and for other coordination of care activities.
- The individual has the right to request further restrictions on certain uses and disclosures of protected health information, but the organization is not required to agree to any requested restriction(s), except disclosures must be restricted to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the protected health information pertains solely to a health care item or service for which the individual or person other than the health plan on behalf of the individual has paid the organization in full.
- The individual has the right to receive confidential communications of protected health information, the right to inspect and copy protected health information, the right to amend protected health information, the right to receive an accounting of disclosures of protected health information and the right to obtain a paper copy of this Notice from the organization upon request.
- The organization is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information and to notify affected individuals following a breach of unsecured protected health information.
- The organization is required to abide by the terms of this Notice currently in effect.
- The organization reserves the right to change the terms of its Notice and to make the new notice provisions effective for all protected health information that it maintains. Individuals may obtain a revised copy of this Notice upon request.
- Individuals may complain to the organization and to the Secretary of the U.S. Department of Health and Human Services if they believe their privacy rights have been violated. Complaints should be directed to the Compliance Officer of the organization at (805) 642-0239. Individuals will not be retaliated against for filing a complaint.
- For further information, individuals should contact the Compliance Officer of the organization at (805) 642-0239.
- This Notice is in effect as of September 23, 2013.
- My signature on the Patient Agreement as to Treatment, Authorization to Pay and Release of Information form is an acknowledgement that I have received a copy of this notice.