THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective Date: April 14, 2003
This Notice of Privacy Practices describes how we
may use and disclose your protected health information to carry out
treatment, payment or health care operations and for other purposes
that are permitted or required by law. It also describes your rights
to access and control your protected health information. "Protected health information" is
information about you, including demographic information, that may
identify you and that relates to your past, present or future physical
or mental health or condition, and related health care services.
Uses and Disclosures of Protected Health Information
You will be asked to sign a consent form. Once you have consented to
the use and disclosure of your health information for treatment, payment
and health care operations by signing the consent form, your physician
will use or disclose your protected health information as described below.
Treatment: Your protected health information may be
used by staff members or disclosed to other healthcare professionals
for the purpose of evaluating your health, diagnosing medical conditions,
and providing treatment. For example, results of laboratory tests and
procedures will be available in your medical record to all health professionals
who may provide treatment or who may be consulted by staff members.
Payment: Your protected health information may be used
to seek payment from your health plan, from other sources of coverage
such as an automobile insurer, or from credit card companies that you
may use to pay for services. For example, obtaining approval for a surgical
procedure may require that your relevant health information be disclosed
to the health plan to obtain approval for the procedure.
Healthcare Operations: Your protected health information
may be used as necessary to support the day-to-day activities and management
of our practice. For example, information on the services you received
may be used to support budgeting and financial reporting, and activities
to evaluate and promote quality and compliance.
We may also share your health information with third party "business
associates" that perform various activities (e.g., collection services,
legal services) for the practice. Whenever an arrangement between our
office and a business associate involves the use or disclosure of your
health information, we will have a written contract that contains terms
that will protect the privacy of your health information.
Other Uses and Disclosures That Do Not Require Your Authorization or
Opportunity to Object Required by Law: Your protected health information may
be used or disclosed to the extent that law requires the use or disclosure.
The use or disclosure will be made in compliance with the law and will
be limited to the relevant requirements of the law. You will be notified,
as required by law, of any such uses or disclosures.
Public Health Reporting: Your protected health information may
be disclosed to public health agencies as required by law. For example,
we are required to report incidences of child abuse or neglect.
Food and Drug Administration: Your protected health information
may be disclosed to a person or company required by the Food and Drug
Administration to report adverse events, product defects or problems,
biologic product deviations, track products, to enable product recalls,
to make repairs or replacements, or to conduct post-marketing surveillance.
Workers’ Compensation: We may disclose your protected
health information to comply with workers’ compensation laws and
other similar legally established programs.
Health Oversight: We may disclose your protected health
information to a health oversight agency for such legally authorized
activities as audits, investigations, and inspections. Oversight agencies
seeking this information include government agencies that oversee the
healthcare system, government benefit programs, other government regulatory
programs and civil rights laws.
Legal Proceedings: Your protected health information may be
disclosed in the course of any judicial or administrative proceeding,
in response to an order of a court or administrative tribunal, in certain
conditions in response to a subpoena, discovery request or other lawful
process. We will disclose only that health information expressly authorized
by such order.
Law Enforcement: Your protected health information may
be disclosed to law enforcement agencies, so long as applicable legal
requirements are met, to support government audits and inspections, to
facilitate law-enforcement investigations, and to comply with government-mandated
reporting.
Coroners, Funeral Directors and Organ Donation: Your protected
health information may be disclosed to a coroner or medical examiner
for identification purposes, determining cause of death or for the coroner
or medical examiner to perform other duties authorized by law. We may
also disclose protected health information to a funeral director, as
authorized by law, in order to permit the funeral director to carry out
their duties. We may disclose such information in reasonable anticipation
of death. Protected health information may be used and disclosed for
cadaveric organ, eye or tissue donation purposes.
Research: Your protected health information may be used
or disclosed to researchers when their research has been approved by
an Institutional Review Board or Privacy Board that has reviewed the
research proposal and established protocols to ensure the privacy of
your protected health information. Your protected health information
may also be used for specified retrospective studies. If this happens,
all identifying information will be removed per federal regulations.
Criminal Activity: Consistent with applicable federal
and state laws, we may disclose your protected health information, if
we believe that the use or disclosure is necessary to prevent or lessen
a serious and imminent threat to the health or safety of a person or
the public. We may also disclose protected health information if it is
necessary for law enforcement authorities to identify or apprehend an
individual.
Inmates: We may use or disclose your protected health information
if you are an inmate of a correctional facility and your physician created
or received your protected health information in the course of providing
care to you.
Military Activity and National Security: When the appropriate
conditions apply, we may use or disclose protected health information
of individuals who are Armed Forces personnel (1) for activities deemed
necessary by appropriate military command authorities; (2) for the purpose
of a determination by the Department of Veterans Affairs of your eligibility
for benefits, or (3) to a foreign military authority if you are a member
of that foreign military services. We may also disclose your protected
health information to authorized federal officials for conducting national
security and intelligence activities, including for the provision of
protective services to the President or others legally authorized.
Required Uses and Disclosures: Under the law, we must make disclosures
to you and when required by the Secretary of the Department of Health
and Human Services to investigate or determine our compliance with the
requirements of Section 164.500 et. Seq of federal regulations.
Uses and Disclosures Where You Have an Opportunity to Object
Others Involved in Your Healthcare: Unless you object, we may
disclose to a member of your family, a relative, a close friend or any
other person you identify, your health information that directly relates
to that person’s involvement in your healthcare. If you are unable
to agree or object to such a disclosure, we may disclose such information
as necessary if we determine that it is in your best interest based on
our professional judgment. We may use or disclose protected health information
to notify or assist in notifying a family member, personal representative
or any other person that is responsible for your care of your location,
general condition or death.
Emergencies: Your protected health information may be used or
disclosed in an emergency treatment situation. As soon as is reasonably
practicable after the emergency situation, your physician will provide
you with a copy of this Notice of Privacy Practices and any other required
consent forms.
Communication Barriers: We may use and disclose your protected
health information if your physician or another physician in the practice
attempts to obtain consent from you, but is unable to do so due to substantial
communication barriers and the physician determines, using professional
judgment, that you intend to consent to use or disclosure under the circumstances.
Disaster Relief Efforts: Unless you object, we may use or disclose
your protected health information to an authorized public or private
entity to assist in disaster relief efforts and to coordinate uses and
disclosures to family or other individuals involved in your healthcare.
If you are unable to agree or object to such a disclosure, we may disclose
such information as necessary if we determine that it is in your best
interest based on our professional judgment.
Additional Uses and Disclosures of Your Protected Health Information Appointment Reminders: Our staff may use your protected
health information to send you appointment reminders, or to call you
for appointment reminders.
Other uses and disclosures require your authorization. Disclosure
of your health information or its use for any purpose other than those
listed above requires your specific written authorization. If you change
your mind after authorizing a use or disclosure of your information,
you may submit a written revocation of the authorization. However, your
decision to revoke the authorization will not affect or undo any use
or disclosure of information that occurred before you notified us of
your decision to revoke your authorization.
YOUR INDIVIDUAL RIGHTS
You have certain rights under the federal privacy standards. These include:
The Right to Inspect and Copy Your Protected Health Information
This means you may inspect and obtain a copy of protected health information
about you that is contained in a designated record set for as long as
we maintain the protected health information. A "designated record
set" contains medical and billing records and any other records
that your physician and the practice use for making decisions about you.
You may inspect or copy your health information by filling out the Patient
Request to Inspect or Copy Protected Health Information form.
Under federal law, however, you may not inspect or copy the following
records; psychotherapy notes; information compiled in reasonable anticipation
of, or use in, a civil, criminal, or administrative action or proceeding,
and protected health information that is subject to law that prohibits
access to protected health information. Depending on the circumstances,
a decision to deny access may be reviewable. In some circumstances, you
may have a right to have this decision reviewed. Please contact our Privacy
Officer if you have questions about access to your medical record.
The Right to Request a Restriction of Your Protected Health Information
This means you may ask us not to use or disclose any part of your protected
health information for the purposes of treatment, payment or healthcare
operations. You may also request that any part of your protected health
information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this
Notice of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may request. If
PacificaSpine believes it is in your
best interest to permit use and disclosure of your protected health information,
your protected health information will not be restricted. If PacificaSpine does agree to the requested
restriction, we may not use or disclose your protected health information
in violation of that restriction unless it is needed to provide emergency
treatment. You may request a restriction in writing by filling out the
Request for Restriction form.
The Right to Request to Receive Confidential Communications from
us by Alternative Means or at an Alternative Location
We will accommodate reasonable requests. We may also condition this accommodation
by asking you for information as to how payment will be handled or specification
of an alternative address or other method of contact. We will not request
an explanation from you as to the basis for the request. If you wish
to receive confidential communications from us by alternative means,
you must fill out the Request for Confidential Communication of Protected
Health Information by Alternative Means or Location form.
The Right to Amend or Submit Corrections to Your Protected Health Information
This means you may request an amendment of protected health information
about you in a designated record set for as long as we maintain this
information. Be advised that you must provide a reason to support the
requested amendment. We will review your request and provide you with
a response. In certain cases, we may deny your request for an amendment.
If we deny your request for amendment, you have the right to file a statement
of disagreement with us and we may prepare a rebuttal to your statement
and will provide you with a copy of any such rebuttal. To submit a request,
you must fill out the Request to Amend Protected Health Information form.
The Right to Receive an Accounting of Certain Disclosures of
Your Protected Health Information
This right applies to disclosures that occurred after April 14, 2003,
for purposes other than treatment, payment or healthcare operations as
described in this Notice of Privacy Practices. It excludes disclosures
we may have made to you, to family members or friends involved in your
care, or for other specified purposes according to the regulation. The
right to receive this information is subject to certain exceptions, restrictions
and limitations. To request an applicable accounting of disclosures,
please fill out the Request for Accounting of Protected Health Information
Disclosures form.
The Right to Obtain a Paper Copy of This Notice from us upon request,
even if you have agreed to accept this notice electronically.
Duties of PacificaSpine
We are required by law to maintain the privacy of your protected health
information and to provide you with this Notice of Privacy Practices.
We are also required to abide by the terms of the notice currently in
effect.
Our Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy
policies and practices at any time. These changes in our policies and
practices may be required by changes in federal and state laws and regulations.
The new notice will be effective for all protected health information
that we maintain at that time. You may see any revised Notice of Privacy
Practices by accessing either of our websites at www.pacificaspine.com, or reading the most current notice on display
in our lobbies. Upon your request, we will provide you with a paper copy
of any revisions.
Complaints
Your privacy is of utmost concern to us. If you believe we have violated
your privacy rights, you should call the matter to our attention by sending
a letter describing the cause of your concern to our privacy officer.
Please address your letter to:
Compliance Coordinator PacificaSpine
1300 Eastman Ave, Suite 205
Ventura, CA 93003
You may also complain to the Secretary
of Health and Human Services. You will not be penalized or retaliated
against for filing a complaint.
Contact Person
If you have any questions about the complaint process or this notice,
please contact our Compliance Coordinator at 805.644.2221.
This notice was published and became effective on April 14, 2003.
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