Highest Standards, Nationally Recognized:
I. 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
II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)
We are legally required to protect the privacy of your PHI, which includes information that can be used to identify you that we’ve created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. We must provide you with this Notice about our privacy practices, and such Notice must explain how, when, and why we will “use” and “disclose” your PHI. A “use” of PHI occurs when we share,
examine, utilize, apply, or analyze such information within our practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of our practice. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, we are legally required to follow the privacy practices described in this Notice.
However, we reserve the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to PHI on file with us already. Before we make any important changes to our policies, we will promptly change this Notice and post a new copy of it in our website. You can also request a copy of this Notice from us, or you can view a copy of it in the Client Handbook or on our website, which is located at (www.avalonmalibu.com).
III. HOW WE MAY USE AND DISCLOSE YOUR PHI.
We will use and disclose your PHI for many different reasons. For some of these uses or disclosures, we will need your prior written authorization; for others, however, we do not. Listed below are the different categories of our uses and disclosures along with some examples of each category.
A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written We can use and disclose your PHI without your consent for the following reasons:
B. you are unable to communicate with us (for example, if you are unconscious or in severe pain) and we think that you would consent to such treatment if you were able to do so.
C. Certain Uses and Disclosures Require You to Have the Opportunity to
D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in sections III A, B, and C above, we will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that we haven’t taken any action in reliance on such authorization) of your PHI by
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
You have the following rights with respect to your PHI:
A. The Right to Request Restrictions on our Uses and Disclosures. You have the right to request restrictions or limitations on our uses or disclosures of your PHI to carry out our treatment, payment, or health care operations. You also have the right to request that we restrict or limit disclosures of your PHI to family members or friends or others involved in your care or who are financially responsible for your care. Please submit such requests to us in writing. We will consider your requests, but we are not legally required to accept If we do accept your requests, we will put them in writing and we will abide by them, except in emergency situations. However, be advised, that you may not limit the uses and disclosures that we are legally required to make.
B. The Right to Choose How We Send PHI to You. You have the right to request that we send confidential information to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). We must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and, when appropriate, you provide us w ithinformation as to how payment for such alternate communications will be handled. We may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.
C. The Right to Inspect and Receive a Copy of Your In most cases, you have the right to inspect and receive a copy of the PHI that we have on you, but you must make the request to inspect and receive a copy of such information in writing. If we don’t have your PHI but we know who does, we will tell you how to get it. We will respond to your request within 30 days of receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have our denial reviewed. If you request copies of your PHI, we will charge you no more than $.25 for each page. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.
D. The Right to Receive a List of the Disclosures We Have Made. You have the right to receive a list of instances, i.e., an Accounting of Disclosures, in which we have disclosed your The list will not include disclosures made for our treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use or disclosure permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; or, disclosures made before April 14, 2003. We will respond to your request for an Accounting of Disclosures within 60 days of receiving such request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we may charge you a reasonable, costbased fee for each additional request.
E. The Right to Amend Your If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request to correct or update your PHI. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.
F. The Right to Receive a Paper Copy of this You have the right to receive a paper copy of this notice even if you have agreed to receive it via email.
V. FILING A COMPLAINT ABOUT OUR PRIVACY PRACTICES
If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section Vl below. You also may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C. 20201.
We will take no retaliatory action against you if you file a complaint about our privacy practices.
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact us at: 888-958-7511.
ACKNOWLEDGEMENT AND CONSENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing this form, you acknowledge receipt of the Notice of Privacy Practices that we have given to you. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. If we change the notice, you may obtain a copy of the revised notice from us by contacting us at 888-958-7511 or by visiting our website (www.avalonmalibu).
If you have any questions about our Notice of Privacy Practices, please contact us at: 888-958-7511.
I acknowledge receipt of the Notice of Privacy Practices of Avalon Malibu in my Client Handbook.
I understand that this facility is a part of an organized healthcare arrangement that includes various third party payers. With my consent; I give permission for these entities to share my health information for purposes of treatment, billing and other healthcare operations.
I understand that there is a publicly posted copy of this organization’s notice of privacy practices that describes how my health information is used and shared. I understand that this facility has the right to change this notice at any time and I may obtain a current copy by contacting the facility’s administration office.