PLEASE READ IT CAREFULLY
The Health Insurance Portability Act of 1996 (“HIPPA”) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by use in any form, whether electronically, on paper, or verbally, are kept properly confidential. This Act gives you the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for entities that misuse health information.
As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may disclose your medical records for each of the following:
• • Treatment: Providing, coordinating or managing healthcare-related services for one or more healthcare providers, such as a physical exam.
• • Payment: Activities such as obtaining reimbursement for services, confirming coverage, billing or collecting procedures and utilization review.
• • Healthcare Operations: Include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service.
We may also create and distribute de-identified health information by removing all references to individually identifying information.
We may contact you to provide appointment reminders or treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures may be made only with your written authorization. You may revoke such authorization in writing and we are required to honor that request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
• The right to request restrictions on certain uses and disclosure of protected health information, including those related to disclosure to family members, friends, or any other person identified by you. We must abide by such restrictions, unless you remove the restriction in writing. However, we are not required to agree to the restriction.
• The right to reasonable requests to receive confidential communication of protection of health information from us by alternative means or at alternative locations.
• The right to inspect or copy your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice upon request.
I understand that as part of my healthcare, this organization originates and maintains healthcare records describing my health history, symptoms, examinations, test results, diagnoses, treatment, and any plans or care regarding future care or treatment. I understand that this information serves as:
• A basis for planning my care and treatment.
• A means of communication among the many health professionals that contribute to my care.
• A source of information for applying my diagnosis and surgical information to my bill.
• A means by which a third party payer can verify, such as assessing quality and reviewing the competence of healthcare professionals.
I understand and have been provided with a “Notice of Privacy Practices”, which provides a more complete description of the information uses and disclosures. I understand that I have the right to review the notice prior to signing this acknowledgment. I understand that the organization reserves the right to change their notice and practices and that prior to implementation, will mail a copy of the revised notice to me at the address I have previously provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or other health-related operations and that the organization is not required to agree to the restrictions requested. I acknowledge receipt of this organization’s “Notice of Privacy Practices”. (Notice effective date or versions: August 30, 2007)
California Assembly Bill 1278: Pursuant to Assembly Bill (AB) 1278, physicians are required to provide notice to patients regarding the Open Payments Database, managed by the US Centers for Medicare and Medicaid Services (CMS). This database is a federal tool used to search payments made by drug and device companies to physicians.
It can be found at https://openpaymentsdata.cms.gov
NOTICE AND ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING
Notice to Patients
Medical doctors are licensed and regulated by the Medical Board of California.
To check up on a license or to file a complaint go to
www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322.