NOTICE OF PRIVACY PRACTICES

C.
When This Medical Practice May Not Use or Disclose Your Health Information
 
  1. Right to Request Special Privacy Protections.  You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed.  If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

  2. Right to Request Confidential Communications.  You have the right to request that you receive your health information in a specific way or at a specific location.  For example, you may ask that we send information to a particular email account or to your work address.  We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

  3. Right to Inspect and Copy.  You have the right to inspect and copy your health information, with limited exceptions.  To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format.  We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary, as allowed by federal and California law. We may deny your request under limited circumstances.  If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision.  If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

  4. Right to Amend or Supplement.  You have a right to request that we amend your health information that you believe is incorrect or incomplete.  You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete.  We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial.  We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is.  If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. You also have the right to request that we add to your record a statement of up to 250 words concerning anything in the record you believe to be incomplete or incorrect. All information related to any request to amend or supplement will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

  5. Right to an Accounting of Disclosures.  You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.

  6. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

D.
Changes to this Notice of Privacy Practices
  We reserve the right to amend our privacy practices and the terms of this Notice of Privacy Practices at any time in the future.  Until such amendment is made, we are required by law to comply with this Notice.  After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received.  We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment.We will also post the current notice on our website.
E.
Complaints

Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

 

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Region IX
Office of Civil Rights
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 (fax)
OCRMail@hhs.gov

The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf.  You will not be penalized in any way for filing a complaint.