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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" 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 and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by our organization, our office staff, and others outside of our office who are involved in your care and treatment — for the purpose of providing health care services to you, paying your health care bills, supporting the operation of the organization, and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services, including coordination with a third party. For example, we would disclose information as necessary to a home health agency that provides care to you, or to a physician to whom you have been referred, to ensure they have what they need to diagnose or treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that relevant information be disclosed to the health plan.

Healthcare Operations

We may use or disclose, as needed, your protected health information to support the business activities of our organization. These activities include, but are not limited to, quality assessment, employee review, accreditation, and arranging for other business activities. For example, we may disclose information to accrediting agencies as part of an accreditation survey, call you by name while you are at our facility, or contact you to check the status of your equipment.

We may use or disclose your protected health information in the following situations without your authorization: as required by law; public health issues as required by law; communicable diseases; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; criminal activity; inmates; military activity; national security; and workers' compensation. Under the law, we must make disclosures to you, and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object, unless required by law. You may revoke this authorization, at any time, in writing — except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of your rights with respect to your protected health information.

Inspect and copy

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access.

Request a restriction

You have the right to request a restriction of your protected health information — to ask us not to use or disclose any part of it for treatment, payment, or healthcare operations, or not to disclose it to family members or friends involved in your care. Your request must state the specific restriction requested and to whom it applies. Our organization is not required to agree to a restriction. If we believe it is in your best interest to permit use and disclosure, your information will not be restricted; you then have the right to use another healthcare professional.

Confidential communications

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us upon request, even if you agreed to accept it electronically.

Access

At all times, you have the right to review your protected health information, with limited exceptions. At your request, we will provide your information in a format other than photocopies if we are able to do so. Your request to obtain access must be in writing; you may obtain a Protected Health Information Access Form using the contact information at the end of this notice. We may charge a reasonable cost-based fee for expenses including copies and staff time: $0.83 per page for the first 30 pages and $0.63 for every page after that, plus $19.00 for staff time to locate and copy your protected health information. Postage will be included if you wish to have your information mailed. If you request a different format, we will charge a cost-based fee for that format; an explanation of fees can be made available.

Amendment

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement; we may prepare a rebuttal and will provide you with a copy.

Accounting of disclosures

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our privacy contact. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions or objections to this form, please ask to speak with our Clinic Director in person or by phone at 949-249-2839.

Associated companies with whom we may do business — such as an answering service or delivery service — are given only enough information to provide the necessary service to you. No medical information is provided. We welcome your comments: please feel free to call us with any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.