2320
BATH ST SUITE 2O3
SANTA
BARBARA, CA 93105
805
687-5538
As
Required by the Privacy Regulations Created as a Result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA)
THIS
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS
PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
PLEASE
REVIEW THIS NOTICE CAREFULLY.
A.
OUR COMMITMENT TO YOUR PRIVACY
Our
practice is dedicated to maintaining the privacy of your individually
identifiable health information (IIHI). In
conducting our business, we will create records regarding you and the treatment
and services we provide to you. We
are required by law to maintain the confidentiality of health information that
identifies you. We also are
required by law to provide you with this notice of our legal duties and the
privacy practices that we maintain in our practice concerning your IIHI.
By federal and state law, we must follow the terms of the notice of
privacy practices that we have in effect at the time.
We
realize that these laws are complicated, but we must provide you with the
following important information:
·
How we may use and disclose your
IIHI
·
Your privacy rights in your IIHI
·
Our
obligations concerning the use and disclosure of your IIHI
The
terms of this notice apply to all records containing your IIHI that are created
or retained by our practice. We
reserve the right to revise or amend this Notice of Privacy Practices.
Any revision or amendment to this notice will be effective for all of
your records that our practice has created or maintained in the past, and for
any of your records that we may create or maintain in the future.
Our practice will post a copy of our current Notice in our offices in a
visible location at all times, and you may request a copy of our most current
Notice at any time.
B.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
[Nancy
Amick, 2320 Bath St. Suite 203, Santa Barbara, CA 93105 805 687-5538]
C.
WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IIHI) IN THE FOLLOWING WAYS
The
following categories describe the different ways in which we may use and
disclose your IIHI.
1.
Treatment.
Our practice may use your IIHI to treat you.
We might use your IIHI in order to write a prescription for you, or we
might disclose your IIHI to a pharmacy when we order a prescription for you.
Many of the people who work for our practice including, but not
limited to, our doctors and nurses may use or disclose your IIHI in order to
treat you or to assist others in your treatment.
Additionally, we may disclose your IIHI to others who may assist in your
care, such as your spouse, children or parents.
Finally,
we may also disclose your IIHI to other health care providers for purposes
related to your treatment.
2.
Payment.
Our practice may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us.
For example, we may contact your health insurer to certify that you are
eligible for benefits, and we may provide your insurer with details regarding
your treatment to determine if your insurer will cover, or pay for, your
treatment. We also may use and disclose your IIHI to obtain payment from
third parties that may be responsible for such costs, such as family members.
Also, we may use your IIHI to bill you directly for services and items.
We may disclose your IIHI to other health care providers and entities to
assist in their billing and collection efforts.
3.
Health Care Operations.
Our practice may use and disclose your IIHI to operate our business.
As examples of the ways in which we may use and disclose your information
for our operations, our practice may use your IIHI to evaluate the quality of
care you received from us, or to conduct cost-management and business planning
activities for our practice. We may
disclose your IIHI to other health care providers and entities to assist in
their health care operations.
4.
Appointment Reminders.
Our practice may use and disclose your IIHI to contact you and remind you
of an appointment, (Unless a restriction form requesting an alternative means of
communication is completed.) You will be contacted by telephone and left a
message on answering machines or voice mail.
Our office may send out postcards to remind patients of appointments.
This correspondence will be labeled personal and confidential.
5.
Release of Information to Family/Friends.
Our practice may release your IIHI to a caregiver or babysitter, family
member that is involved in your care, or who assists in taking care of you
6.
Disclosures Required By Law.
Our practice will use and disclose your IIHI when we are required to do
so by federal, state or local law.
D.USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIALCIRCUMSTANCES
The
following categories describe unique scenarios in which we may use or disclose
your identifiable health information:
1.
Public Health Risks.
Our practice may disclose your IIHI to public health authorities that are
authorized by law to collect information for the purpose of:
·
maintaining vital records, such as
births and deaths
·
reporting child abuse or neglect
·
preventing or controlling disease,
injury or disability
·
notifying a person regarding
potential exposure to a communicable disease
·
notifying a person regarding a
potential risk for spreading or contracting a disease or condition
·
reporting reactions to drugs or
problems with products or devices
·
notifying individuals if a product
or device they may be using has been recalled
·
notifying appropriate government
agency(ies) and authority(ies) regarding the potential abuse or neglect of an
adult patient (including domestic violence); however, we will only disclose this
information if the patient agrees or we are required or authorized by law to
disclose this information
·
notifying your employer under
limited circumstances related primarily to workplace injury or illness or
medical surveillance.
2.
Health Oversight Activities.
Our practice may disclose your IIHI to a health oversight agency for
activities authorized by law. Oversight
activities can include, for example, investigations, inspections, audits,
surveys, licensure and disciplinary actions; civil, administrative, and criminal
procedures or actions; or other activities necessary for the government to
monitor government programs, compliance with civil rights laws and the health
care system in general.
3.
Lawsuits and Similar Proceedings.
Our practice may use and disclose your IIHI in response to a court or
administrative order, if you are involved in a lawsuit or similar proceeding.
We also may disclose your IIHI in response to a discovery request,
subpoena, or other lawful process by another party involved in the dispute, but
only if we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested.
4.
Law Enforcement.
We may release IIHI if asked to do so by a law enforcement official:
·
Regarding a crime victim in certain
situations, if we are unable to obtain the persons agreement
·
Concerning a death we believe has
resulted from criminal conduct
·
Regarding criminal conduct at our
offices
·
In response to a warrant, summons,
court order, subpoena or similar legal process
·
To identify/locate a suspect,
material witness, fugitive or missing person
·
In an emergency, to report a crime
(including the location or victim(s) of the crime, or the description, identity
or location of the perpetrator)
8. Serious Threats to
Health or Safety. Our practice may use and disclose your IIHI when necessary to
reduce or prevent a serious threat to your health and safety or the health and
safety of another individual or the public.
Under these circumstances, we will only make disclosures to a person or
organization able to help prevent the threat.
9.
Military.
Our practice may disclose your IIHI if you are a member of U.S. or
foreign military forces (including veterans) and if required by the appropriate
authorities.
10.
National Security.
Our practice may disclose your IIHI to federal officials for intelligence
and national security activities authorized by law.
We also may disclose your IIHI to federal officials in order to protect
the President, other officials or foreign heads of state, or to conduct
investigations.
11.
Inmates.
Our practice may disclose your IIHI to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be necessary: (a) for the
institution to provide health care services to you, (b) for the safety and
security of the institution, and/or (c) to protect your health and safety or the
health and safety of other individuals.
12.
Workers Compensation.
Our practice may release your IIHI for workers compensation and
similar programs.
You have the following rights regarding the IIHI that we maintain about you:
1.
Confidential Communications.
You have the right to request that our practice communicate with you
about your health and related issues in a particular manner or at a certain
location. For instance, you may ask
that we contact you at home, rather than work.
In order to request a type of confidential communication, you must make a
written request to Nancy Amick, 805 687-5538, specifying the requested
method of contact, or the location where you wish to be contacted.
Our practice will accommodate reasonable
requests. You do not need to give a
reason for your request.
2. Requesting Restrictions. You have the right to
request a restriction in our use or disclosure of your IIHI for treatment,
payment or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your IIHI to
only certain individuals involved in your care or the payment for your care,
such as family members and friends. We
are not required to agree to your
request; however, if we do agree, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information is necessary
to treat you. In order to request a
restriction in our use or disclosure of your IIHI, you must make your request in
writing to [Nancy Amick, 2320 Bath St.
Suite 203 Santa Barbara, CA 93105]. Your
request must describe in a clear and concise fashion:
(a)
the information you wish restricted;
(b)
whether you are requesting to limit our practices use, disclosure or
both; and
(c)
to whom you want the limits to apply.
3.
Inspection and Copies.
You have the right to inspect and obtain a copy of the IIHI that may be
used to make decisions about you, including patient medical records and billing
records, but not including psychotherapy notes.
You must submit your request in writing to [Nancy
Amick, 2320 Bath St. Suite 203, Santa Barbara, CA 93105] in order to inspect
and/or obtain a copy of your IIHI. Our
practice may charge a fee for the costs of copying, mailing, labor and supplies
associated with your request. Our
practice may deny your request to inspect and/or copy in certain limited
circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will
conduct reviews.
4.
Amendment.
You may ask us to amend your health information if you believe it is
incorrect or incomplete, and you may request an amendment for as long as the
information is kept by or for our practice.
To request an amendment, your request must be made in writing and
submitted to [Nancy Amick, 2320 Bath St. Suite 203 Santa Barbara, CA 93105].
You must provide us with a reason that supports your request for
amendment. Our practice will
deny your request if you fail to submit your request (and the reason supporting
your request) in writing. Also, we may deny your request if you ask us to amend
information that is in our opinion: (a) accurate and complete; (b) not part of
the IIHI kept by or for the practice; (c) not part of the IIHI which you would
be permitted to inspect and copy; or (d) not created by our practice, unless the
individual or entity that created the information is not available to amend the
information.
5.
Accounting of Disclosures.
All of our patients have the right to request an accounting of
disclosures. An accounting of
disclosures is a list of certain non-routine disclosures our practice has
made of your IIHI for non-treatment, non-payment or non-operations purposes.
Use of your IIHI as part of the routine patient care in our practice is
not required to be documented. For
example, the doctor sharing information with the nurse; or the billing
department using your information to file your insurance claim.
In order to obtain an accounting of disclosures, you must submit your
request in writing to [Nancy Amick, 805
687-5538]. All requests for an
accounting of disclosures must state a time period, which may not be
longer than six (6) years from the date of disclosure and may not include dates
before April 14, 2003. The first
list you request within a 12-month period is free of charge, but our practice
may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with
additional requests, and you may withdraw your request before you incur any
costs.
6.
Right to a Paper Copy of This Notice.
You are entitled to receive a paper copy of our notice of privacy
practices. You may ask us to give
you a copy of this notice at any time. To
obtain a paper copy of this notice, contact [Nancy
Amick, 805 687-5538].
7.
Right to File a Complaint.
If you believe your privacy rights have been violated, you may file a
complaint with our practice or with the Secretary of the Department of Health
and Human Services. To file a
complaint with our practice, contact [Nancy Amick, 805 687-5538].
All complaints must be submitted in writing. You
will not be penalized for filing a complaint.
8.
Right to Provide an Authorization for Other Uses and Disclosures.
Our practice will obtain your written authorization for uses and
disclosures that are not identified by this notice or permitted by applicable
law. Any authorization you provide
to us regarding the use and disclosure of your IIHI may be revoked at any time in
writing. After you revoke your authorization, we will no longer use or
disclose your IIHI for the reasons described in the authorization.
Please note, we are required to retain records of your care.
Again,
if you have any questions regarding this notice or our health information
privacy policies, please contact [Nancy Amick, 805 687-5538]
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