NOTICE OF PRIVACY PRACTICES
Effective Date: April 1, 2014
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The following pages describe different ways we use your health information and discloses your health information to persons and entities. Each description is of a category of use or disclosure. We have not listed every use or disclosure within the categories, but all permitted uses and disclosures will fall within one of the following categories:
Treatment: We may use health information about you to provide you with medical treatment and services. We may disclose health information about you to other medical professionals and personnel who are involved in taking care of you. Unless you tell us not to do so, we may also disclose health information about you to people outside the hospital (or other facility) who may assist in providing your medical care after you leave the hospital (or other facility), such as family members or others. Also, we may request information about you from a doctor’s office, or from another hospital (or other facility) where you were admitted, in order to coordinate and manage your care among all the health care providers who take part in providing your care.
Payment: We may use and disclose health information about you in order to obtain authorization from your insurance company, when required, to provide you services and treatment. We may also use and disclose health information about you in order to bill for the services we provided, and to collect payment from you, an insurance company, or a third party. For example, we may tell your health plan about a future treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
Health Care Operations: We may use and disclose health information about you for health care operations, including, for example: quality assurance, peer review, and risk management activities; administrative activities, including financial and business planning and development; and customer service activities, including investigation of complaints. These uses and disclosures are designed to assist in our operation and to promote the delivery of quality care to all of our patients. For example, we may use medical information to review our treatment and services and to evaluate the performance of physicians who care for you. Additionally, we may use and disclose health information to get your plan to authorize services or referrals.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples of business associates include billing companies, management consultants, quality assurance reviewers, etc. We may disclose your health information to our business associates so that they can perform the job we’ve asked them to do. To protect your health information, we require our business associates to sign a contract or other written agreement that states they will appropriately safeguard and protect the confidentiality of your health information.
Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care. These appointment reminders may be initiated by an automated voice message system. If you are not home, we may leave information on your answering machine or in a message left with a person answering the phone. This information may include, but is not limited to, preoperative or postoperative instructions.
Sign In Sheet: We may use or disclose health information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.
Individuals Involved in Your Care or Payment for Your Care: We may disclose health information about you to a friend or family member who is involved in your medical care or helps pay for your care, unless you tell us in advance not to do so.
USE OR DISCLOSURE WITH YOUR SPECIFIC WRITTEN “AUTHORIZATION”
If there are reasons we need to use your information that have not been described in the sentences above, we will obtain your written permission (called “authorization”). If you authorize us 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 health information about you for the reasons stated in your written authorization. Please understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Some typical disclosures that require your written authorization, or the written authorization of your representative are for disclosure of drug and alcohol abuse treatment, HIV and AIDS test results, and mental health treatment.
SPECIAL SITUATIONS THAT DO NOT REQUIRE YOUR AUTHORIZATION
Federal, state or local law permits the following disclosures of your health information without any verbal or written permission from you, although this list is not intended to be all-inclusive:
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 organ or tissue donation and transplantation.
Military and Veterans: If you are a member of the armed forces, we may release health information about you as required by military command authorities.
Worker’s Compensation: We may release health information about you for worker’s compensation or similar programs if you have a work-related injury. These programs provide benefits for work-related injuries.
Averting a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health or safety, or the health and safety of another person or the public. These disclosures would be made only to someone able to help prevent the threat.
Public Health Activities: We may disclose health information about you for public health activities. These generally include the following:
To prevent or control disease, injury or disability.
• To report births and deaths.
• To report child or dependent adult abuse or neglect.
• To report reactions to medications, problems with products or other adverse events.
• To notify people of recalls of products they may be using.
• To notify a person who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition.
• To notify the appropriate government authority if we believe a patient has been the victim of
abuse (including elder abuse), neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure and other proceedings. These activities are necessary for the government 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. We may disclose health information about you in response to a subpoena, discovery request or other lawful process, if reasonable efforts have been made to notify you of the request and you have not objected, or if your time to object has expired and you have not objected, or if your objections have been resolved by a court or administrative order.
Law Enforcement: We may disclose health information if asked to do so by law enforcement officials for any aspect of a criminal investigation or emergency.
Coroners, Medical Examiners and Funeral Home Directors: We may disclose health information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death of a person. We may also release health information about patients at our facility to funeral home directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may disclose health information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Inmates: If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose health information about you to the correctional institution or the law enforcement official. This is necessary for the correctional institution to provide you with health care, to protect your health and safety and the health and safety of others, or for the safety and security of the correctional institution.
Legal Requirements: We will disclose health information about you without your permission when required to do so by federal, state or local law.
Change of Ownership: In the event that this medical practice is sold or merges with another organization, your health information/record will become the property of the new owner. The information in the record belongs to you, and you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
Website: You may access a copy of this Notice electronically on our website.
YOUR HEALTH INFORMATION RIGHTS
You have the following rights regarding your information in our possession.
1. Request a restriction on certain uses and disclosures of your information. You have the right to request restrictions on certain uses and disclosures of your health information. Your request must be in writing and specify what information you want to limit and what limitation on our use or disclosure of that information you wish to have imposed. We are not required by law to agree to your request, unless (a) your request is for a restriction on disclosure to a health plan for payment or health care operations purposes; and, (b) the applicable health information pertains solely to services for which you paid out-of-pocket in full. Otherwise, we reserve the right to accept or reject your request. If we do agree to your request, we will comply with your request to the best of our ability unless the information is needed to provide you with emergency treatment. If we reject your request, we will notify you of our decision.
2. Obtain a paper copy of this Notice upon request. You have a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.
3. Inspect and request a copy of your health record for a fee. Your request for inspection or copies must be in writing. A reasonable fee for copies will be charged. We may deny your request under very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed by another health care professional chosen by someone on our health care team. We will abide by the outcome of that review.
Effective February 17, 2010, if we use or maintain electronic health records, you have the right to receive an electronic copy of your electronic health records or to ask that we transmit your health information to a person or entity that you designate. Your request must be in writing, and your choice of whether to receive the electronic copy or to have the copy transmitted to a third party must be clear, conspicuous, and specific. You will be charged a fee equivalent to our labor costs in responding to your request.
4. Request an amendment to your health record. If you feel that information included in your medical record is incorrect or incomplete, you may request an amendment. Your request must be in writing and include the reasons you believe the information is incorrect or incomplete. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. Also, we may deny your request if the information you want to amend was not created by us (unless the person or entity that created the information is no longer available to make the amendment), is not part of the information kept by us, is not part of the information which you would be permitted to inspect and copy, and if the information is accurate and complete as stated. Please note that even if we accept your request, we are not required to delete any information from your health record. You also have the right to request that we add to your record a statement of 100 words concerning any statement or item you believe to be incorrect or incomplete.
5. Obtain an accounting of disclosures of your health information.
a. Paper Records. You have a right to receive an accounting of disclosures of your health information made by us, except that we do not have to account for the disclosures
provided to you or pursuant to your written authorization, or as described in the paragraphs of this Notice, headed “Treatment”, “Payment”, “Health Care Operations”, “Individuals Involved in Your Care or Payment for Your Care”, “Military and Veterans”, National Security and Intelligence Activities”, or “Inmates” or disclosures for purposes of 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 that we have received notice from that agency or official that providing the accounting would be reasonably likely to impede their activities.
b. Electronic Records. If we use electronic health records, you have the right to receive an accounting of disclosures of your health information made from electronic health records, including disclosure for the purposes of treatment, payment, and health care operations. The accounting will include disclosures made from electronic health records on and after the later of (a) January 1, 2011; or, (b) the date on which we acquired an electronic health record.
Your request must be in writing.
6. Request communication of your health information by alternative means or locations. 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 may ask that we only contact you at work or by mail. We will accommodate all requests that are reasonable for our system and/or staff capabilities. Your request must be in writing and specify how or where you wish to receive these communications.
7. Revoke your authorization. You may revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Complain about any aspect of our health information practices to us or to the Department of Health and Human Services of the United States. You may complain to PMC and the Secretary of Health and Human Services about this Notice or how we handle your health information. Complaints should be directed in writing to the address below. We will not retaliate against you for filing a complaint.
Privacy Officer, Pain Medicine Consultants, 2250 Morello Ave, Pleasant Hill, CA 94523
CHANGES TO THIS NOTICE
We reserve the right to change this notice without written notification to you. We reserve the right to make the revised or changed notice effective for health information we already have about you.
If you have any questions about this notice, please contact Privacy Officer at (925) 287-1256.
1050 Northgate Drive, Suite 460
San Rafael, California 94903
of medicine and is not a substitute for treatment from a doctor or therapist.
“This site is protected by an SSL certificate. However, there is some inherent risk of compromise of
private health information by electronically transmitting it through this site”