PRIVACY NOTICE

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 CAREFULLY.

As health care providers, we are required by law, as outlined by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the privacy of your personal health information (PHI) as follows:
\tTo maintain privacy of protected PHI.
\tTo provide patients with notice of physicians legal duties regarding PHI
\tTo provide patients with notice of privacy practices
\tTo abide by the terms of the physician’s privacy notice then in effect
\tTo reserve the right to change the terms of the privacy notice
\tTo notify patients of new privacy notice provisions

Your PHI may be disclosed for the following reasons:
\tTreatment: Your PHI may be disclosed to front office and technical staff
\twhile performing duties such as pharmacy calls, messages, appointments
\tand other related items required for the treatment of a patient.

\tPayment: Your PHI may be sent to an outside billing service for collection of \tyour claim. When your claim is sent to your insurance company it will contain \tyour diagnosis and procedure codes. Your insurance company may also request \tyour medical records for review of your claim.

\tHealth Care
\tOperations: When receiving services in our office your PHI may be shared with \toutside providers. If we refer to another physician or specialist we may send your \trecords for that physician’s review. When utilizing any laboratory or pathology \tservices your diagnosis codes will be given to the laboratory or the pathologist \tprocessing your specimen.

Your PHI may be disclosed without authorization to your health plan, or providers that have indirect treatment relationships with patients such as the laboratory. This does not in any way exclude these entities from keeping your health care private.

-1-
\tOur office may contact you to remind you of an upcoming appointment, to discuss results and/or treatment options, for insurance related issues or other health care related benefits and services that may be of interest to you.

\tBy law, we may disclose you PHI without your consent in an emergency ( when a provider is required by law to treat a patient) or when there are substantial communication barriers.

\tUses and disclosures not listed above can only be made with your authorization. Such authorization may be revoked pursuant to the privacy regulations.

As a patient, the law has outlined your rights. They are as follows:

•\tRight to request restrictions on use and disclosure of PHI (physician is not required to agree to requested restriction)
•\tRight to receive confidential communication of PHI
•\tRight to inspect and copy PHI
•\tRight to amend PHI ( physician not required to agree to amendment)
•\tRight to receive an accounting of disclosures of PHI
•\tRight to obtain paper copy of privacy notice

You may at any time request any of your rights mentioned above by speaking with a member of our staff.

Our office staff will always take reasonable steps to limit the use of disclosure of your PHI to the minimum required. If you feel that a physician or member of our staff has disclosed your PHI in a manner that is deemed inappropriate by HIPAA standards you have the right to file a complaint with the physician’s office or the Department of Health and Human Services (HHS). You may file a complaint with the physician’s compliance officer and every effort will be made to resolve the issue. There will be no retaliation for filing a complaint and you will not be dismissed from the practice for doing so.

If you have any questions regarding the above notice you may speak with your doctor or contact our compliance officer at (714) 965-5130.

-2-