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TAO OF WELLNESS - 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.
If you have any questions about this
notice, please contact Adriana Rivera, designated privacy official
contact of our office at (310) 917-2200, located at 1131 Wilshire Blvd.,
#300, Santa Monica, CA 90401.
WHO WILL FOLLOW THIS NOTICE
This notice describes the information
privacy practices followed by our practitioners, employees, and other
office personnel. The practices described in this notice will also be
followed by health care providers you consult with by telephone (when
your regular health care provider from our office is not available) who
provide “call coverage” for your health care provider.
YOUR HEALTH INFORMATION
This notice applies to the
information and records we have about your health, health status, and
the health care services you receive at this office.
We are required by law to give you
this notice. It will tell you about the ways in which we may use and
disclose health information about you and describes you rights and our
obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH
INFORMATION ABOUT YOU
For Treatment We may use
health information about you to provide you with medical treatment or
services. We may disclose health information about you to doctors,
nurses, technicians, office staff or other personnel who are involved in
taking care of you and your health.
For example, your practitioner may be
treating you for a respiratory condition and may need to know if you
have other health problems that could complicate your treatment. The
practitioner may use your medical history to decide what treatment is
best for you. The practitioner may also tell another doctor about your
condition so that the doctor can help determine the most appropriate
care for you.
Different personnel in our office may
share information about you and disclose information to people who do
not work in our office in order to coordinate your care, such as
scheduling lab work and ordering x-rays. Family members and other health
care providers may be part of your medical care outside this office and
may require information about you that we have.
For Payment We may use and
disclose health information about you so that the treatment and services
you receive at this office may be billed to and payment may be collected
from you, an insurance company or a third party. For example, we may
need to give your health plan information about a service you received
here so your health plan will reimburse you for the service. We may also
tell your health plan about a treatment you are going to receive to
obtain prior approval, or to determine whether your plan will cover the
treatment.
For Health Care Operations We
may use and disclose health information about you in order to run the
office and make sure that you and our other patients receive quality
care. For example, we may use your health information to evaluate the
performance of our staff in caring for you. We may also use health
information about all or many of our patients to help us decide what
additional services we should offer, how we can become more efficient,
or whether certain new treatments are effective.
Appointment Reminders We may
contact you as a reminder that you have an appointment for treatment or
medical care at the office.
Treatment Alternatives We may
tell you about or recommend possible treatment options or alternatives
that may be of interest to you.
Health-Related Products and
Services We may tell you about health-related products or services
that my be of interest to you.
Please notify us if you do not wish
to be contacted for appointment reminders, or if you do not wish to
receive communications about treatment alternatives or health-related
products and services. If you advise us in writing (at the address
listed at the top of this Notice) that you do not wish to receive such
communications, we will not use or disclose your information for these
purposes.
You may revoke your Consent,
at any time by giving us written notice. Your revocation will be
effective when we receive it, but it will not apply to any uses and
disclosures which occurred before that time.
If you do revoke your Consent, we
will not be permitted to use or disclose information for purposes of
treatment, payment or health care operations, and we may therefore
choose to discontinue providing you with health care treatment and
services.
SPECIAL SITUATIONS
We may use or disclose health
information about you without your permission for the following
purposes, subject to all applicable legal requirements and limitations:
To Avert a Serious Threat to
Health of Safety We may use and disclose health 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.
Required By Law We will
disclose health information about you when required to do so by federal,
state or local law.
Research We may use and
disclose health information about you for research projects that are
subject to a special approval process. We will ask you for your
permission if the researcher will have access to your name, address or
other information that reveals who you are, or will be involved in your
care at the office.
Organ and Tissue Donation If
you are an organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or tissue
transplantation or to an organ donation bank, as necessary to facilitate
such donation and transplantation.
Military, Veterans, National
Security and Intelligence If you are or were a member of the armed
forces, or part of the national security or intelligence communities, we
may be required by military command or other government authorities to
release health information about you. We may also release information
about foreign military personnel to the appropriate foreign military
authority.
Workers’ Compensation We may
release health information about you for workers’ compensation or
similar programs. These programs provide benefits for work-related
injuries or illness.
Public Health Risks We may
disclose health information about you for public health reasons in order
to prevent or control disease, injury or disability; or report births,
deaths, suspected abuse or neglect, non-accidental physical injuries,
reactions to medications or problems with products.
Health Oversight Activities We
may disclose health information to a health oversight agency for audits,
investigations, inspections, or licensing purposes. These disclosures
may be necessary for certain state and federal agencies to monitor the
health care system, government programs, and compliance with civil
rights laws.
Lawsuits and Disputes If you
are involved in a lawsuit or a dispute, we may disclose health
information about you in response to a court or administrative order.
Subject to all applicable legal requirements, we may also disclose
health information about you in response to a subpoena.
Law Enforcement We may release
health information if asked to do so by a law enforcement official in
response to a court order, subpoena, warrant, summons or similar
process, subject to all applicable legal requirements.
Coroners, Medical Examiners and
Funeral Directors We may release health information to a coroner or
medical examiner. This may be necessary, for example, to identify a
deceased person or determined the cause of death.
Information Not Personally
Identifiable We may use or disclose health information about you in
a way that does not personally identify you or reveal who you are.
Family and Friends We may
disclose health information about you to your family members or friends
if we obtain your verbal agreement to do so or if we give you an
opportunity to object to such a disclosure and you do not raise an
objection. We may also disclose health information to your family or
friends if we can infer from the circumstances, based on our
professional judgment that you would not object. For example, we may
assume you agree to our disclosure of your personal health information
to your spouse when you bring your spouse with you into the exam room
during treatment or while treatment is discussed.
In situations where you are not
capable of giving Consent (because you are not present or due to your
incapacity or medical emergency), we may, using our professional
judgment, determine that a disclosure to your family member or friend is
in your best interest. In that situation, we will disclose only health
information relevant to the person’s involvement in your care. For
example, we may inform the person who accompanied you to the emergency
room that you suffered a heart attack and provide updates on your
progress and prognosis. We may also use our professional judgment and
experience to make reasonable inferences that it is in your best
interest to allow another person to act on your behalf to pick up, for
example, filled prescriptions, medical supplies, or X-rays.
OTHER USES AND DISCLOSURES OF
HEALTH INFORMATION
We will not use or disclose your
health information for any purpose other than those identified in the
previous sections without your specific, written Authorization. We must
obtain your Authorization separate from any Consent we may have obtained
from you. If you give us Authorization to use or disclose health
information about you, you may revoke that Authorization, in writing, at
any time. If you revoke your Authorization, we will no longer use or
disclose information about you for the reasons covered by your written
Authorization, but we cannot take back any uses or disclosures already
made with your permission.
If we have HIV or substance abuse
information about you, we cannot release that information without a
special signed, written Authorization (different than the Authorization
and Consent mentioned above) from you. In order to disclose these types
of records for purposes of treatment, payment or health care operations,
we will have to have both your signed Consent and a special written
Authorization that complies with the law governing HIV or substance
abuse records.
YOUR RIGHTS REGARDING HEALTH
INFORMATION ABOUT YOU
You have the following rights
regarding health information we maintain about you:
Rights to Inspect and Copy You have
the right to inspect and copy your health information, such as medical
and billing records, that we use to make decisions about your care. You
must submit a written request to Adriana Rivera in order to inspect
and/or copy your health information. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or
other associated supplies. We may deny your request to inspect and/or
copy in certain limited circumstances. If you are denied access to your
health information, you may ask that the denial be reviewed. If such a
review is required by law, we will select a licensed health care
professional to review your request and our denial. The person
conducting the review will not be the person who denied your request,
and we will comply with the outcome of the review.
Right to Amend If you believe health
information we have about you is incorrect or incomplete, you may ask us
to amend the information. You have the right to request an amendment as
long as the information is kept by this office.
To request an amendment, complete and
submit a Medical Record Amendment/Correction Form to Adriana Rivera. We
may deny your request for an amendment if it is not in writing or does
not include a reason to support the request. In addition, we may deny
your request if you ask us to amend information that:
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We did not create, unless the
person or entity that created the information is no longer available
to make the amendment.
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Is not part of the health
information that we keep.
-
You would not be permitted to
inspect and copy.
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Is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a
list of the disclosures we made of medical information about you for
purposes other than treatment, payment and health care operations. To
obtain this list, you must submit your request in writing to Adriana
Rivera. It must state a time period, which may not be longer than six
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,
electronically). 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 the health
information we use or disclose about you for treatment, payment or
health care operations. You also have the right to request a limit on
the health information we disclose about you to someone who is involved
in your care or the payment for it, like a family member or friend. For
example, you could ask that we not use or disclose information about a
surgery you had.
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.
To request restrictions, you may
complete and submit the Request For Restrictions On Use/Disclosure Of
Medical Information to Adriana Rivera.
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 may complete and submit the Request For Restriction
On Use/Disclosure Of Medical Information And/Or Confidential
Communication to Adriana Rivera. 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. You may ask us to
give you a copy of this notice at any time. Even if you have agreed to
receive it electronically, you are still entitled to a paper copy. To
obtain such a copy, contact Adriana Rivera.
CHANGES TO THIS NOTICE
We reserve the right to change this
notice, and 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 summary of the current notice in
the office with its effective date in the top right hand corner. You are
entitled to a copy of the notice currently in effect.
COMPLAINTS
If you believe your privacy rights
have been violated, you may file a complaint with our office or with the
Secretary of the Department of Health and Human Services. To file a
complaint with our office, contact Adriana Rivera, detailed information
provided at the beginning of this notice. You will not be penalized for
filing a complaint. |
