NOTICE OF PRIVACY PRACTICES FOR ESA DOCTOR MEDICAL CLINIC OF CALIFORNIA, INC., P.C.
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.
ESA Doctor Medical Clinic , Inc., P.C. d/b/a ESA Doctor Clinic (“ESA Doctor”) is committed to protecting your privacy and understands the importance of safeguarding your medical information. We are required by federal law to maintain the privacy of health information that identifies you or that could be used to identify you (known as “Protected Health Information” or “PHI”). We also are required to provide you with this Notice of Privacy Practices (“Notice”), which explains our legal duties and privacy practices, as well as your rights, with respect to PHI that we collect and maintain. We are required by federal law to abide by the terms of this Notice currently in effect. However, we reserve the right to change the privacy practices described in this Notice and make the new practices effective for all PHI that we maintain Should we make such a change, you may obtain a revised Notice by calling our office and requesting a revised copy be sent in the mail, or accessing our website.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
A. Routine Uses and Disclosures of Protected Health Information
We are permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The following are examples of the types of routine uses and disclosures of PHI that we are permitted to make. While this list is not exhaustive, it should give you an idea of the routine uses and disclosures we are permitted to make.
For Treatment: We will use and disclose your PHI to provide, coordinate, or manage your treatment. We may disclose medical information about you to our physicians, to other health care providers treating you who are not part of ESA Doctor, and to other personnel involved in your health care.
For Payment: Your PHI will be used, as needed, to obtain payment for the health care services we provide you. We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you. The insurance company may use that information in connection with making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
For Health Care Operations: We may use or disclose your PHI in order to support the business activities of this medical practice. These activities may include, but are not limited quality assessment activities, practice accreditation, employee review activities, billing, and licensing, marketing, legal advice, accounting support and conducting or arranging for other business activities. For example, we may use or disclose your protected health information, as necessary, to contact you by mail to remind you of your appointment by reminder cards.
California law provides that we may disclose your PHI under certain circumstances to organized committees and agents of professional societies or of medical staffs of licensed hospitals, licensed health care service plans, professional standards review organizations, and persons or organizations insuring, responsible for or defending professional liability we may incur.
B. Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object We may use or disclose your PHI in the following situations without your authorization or providing you the opportunity to object
Required by the Secretary of the Department of Health and Human Services: We may be required to disclose your PHI to the Secretary of the Department of Health and Human Services (“Secretary”) to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
Required By Law: We may use or disclose your PHI to the extent that the use or disclosure is otherwise required by federal, state or local law. Public Health: We may disclose your PHI for public health activities, such as disclosures to a public health authority or other government agency that is permitted by law to collect or receive the information (e.g., the Food and Drug Administration).
California law provides that we may disclose basic information, including your name, city of residence, age, sex, and general condition to a state or federally-recognized disaster relief organization for purposes of responding to disaster welfare inquiries.
California law further provides that we may not disclose HIV status without your authorization or other person authorized by law, except as authorized by state law or required under federal law.
Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: If you have been a victim of abuse, neglect, or domestic violence, we may disclose your PHI to a government agency authorized to receive such information. In addition, we may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect.
California Minors: If you are a minor, California law provides that we may disclose your PHI to a county social worker, a probation officer, or any other person who is legally authorized to have custody or care of a minor for the purpose of coordinating certain health care services and medical treatment provided to the minor.
Judicial and Administrative Proceedings: We may disclose your PHI in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain circumstances, in response to a subpoena, discovery request or other lawful process.
California law provides that we may disclose your PHI if the disclosure is compelled by a board, commission or administrative agency for purposes of adjudication or pursuant to an investigative subpoena or is compelled by an arbitrator or arbitration panel pursuant to a subpoena duces tecum under certain circumstances.
California law further provides that we may disclose your PHI to the extent it is relevant to your condition, care or treatment to a probate court investigator in the course of an investigation required or authorized in a conservatorship proceeding under California law.
Law Enforcement: We may disclose your PHI, so long as applicable legal requirements are met, for law enforcement purposes, such as providing information to the police about the victim of a crime.
California law provides that we may disclose your PHI to a governmental law enforcement agency pursuant to a lawfully issued search warrant.
Coroners and Funeral Directors: We may disclose your PHI to a coroner, medical examiner, or funeral director if it is needed to perform their legally authorized duties.
Organ Donation: If you are an organ donor, we may disclose your PHI to organ procurement organizations as necessary to facilitate organ donation or transplantation.
If you are a tissue donor, California law provides that we may disclose your PHI to a tissue bank as necessary to facilitate tissue donation or transplantation.
Research: Under certain circumstances, we may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
Serious Threat to Health or Safety: We may disclose your PHI if we believe it is necessary to prevent a serious and imminent threat to the public health or safety and the disclosure is made to someone we reasonably believe is able to prevent or lessen the threat.
Specialized Government Functions: When the appropriate conditions apply, we may disclose PHI for purposes related to military or national security concerns, such as for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits.
Workers’ Compensation: We may disclose your PHI as necessary to comply with workers’ compensation laws and other similar programs.
Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility and we created or received your PHI in the course of providing care to you.
Business Associates: We may disclose your PHI to persons who perform functions, activities or services to us or on our behalf that require the use or disclosure of PHI. To protect your health information, we require the business associate to appropriately safeguard your information.
C. Uses and Disclosures That May Be Made Either With Your Agreement or the Opportunity to Object
Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, orally or in writing, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such 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 your PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition.
California law provides that we may disclose such information to a family member, other relative, domestic partner, a close personal friend, or any other person identified by you.
D. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Marketing: We must obtain your written authorization to use and disclose your PHI for most marketing purposes.
Sale of PHI: We must obtain your written authorization for any disclosure of your PHI which constitutes a sale of PHI.
California law provides that we may not intentionally share, sell, use for marketing, or otherwise use your medical information for a purpose not necessary to provide health care services to you, except to the extent expressly authorized by you.
Other Uses: Other uses and disclosures of your PHI, not described above, will be made only with your written authorization. You may revoke your authorization, at any time, in writing, except to the extent that we have taken action in reliance on the authorization.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have certain rights regarding your PHI, which are explained below. You may exercise these rights by submitting a request in writing to our Privacy Officer.
- A. You have the right to inspect and copy your PHI. If you would like to see or copy your PHI that is contained in a designated record set (e.g., medical and billing records), we are required to provide you access to such PHI for inspection and copying within 30 days after receipt of your request (with up to a 30-day extension if needed). We may charge you a reasonable fee to cover duplication, mailing and other costs incurred by us in complying with your request. In addition, there are situations where we may deny your request for access to your PHI. For example, we may deny your request if we believe the disclosure will endanger your life or that of another person. Depending on the circumstances of the denial, you may have a right to have this decision reviewed.
- Under California law, we must permit you or your representative to inspect your medical records during business hours within five (5) working days after receipt of a written request by you or your representative.
- California law further provides that you or your representative are entitled to copies of all or any portion of your patient records upon presenting a written request specifying the records to be copied, together with a fee to defray the cost of copying, that shall not exceed twenty-five cents ($0.25) per page or fifty cents ($0.50) per page for records that are copied from microfilm and any additional reasonable clerical costs incurred in making the records available. We are required to ensure that the copies are transmitted within fifteen (15) days after receiving the written request. We may choose to prepare a summary of your medical record rather than allowing access to the entire record, in which case we must make the summary of the record available to you within ten (10) working days (with up to a 20-day extension if needed) from the request date.
- B. You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for purposes of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. 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, except we must agree not to disclose your PHI to your health plan if the disclosure (1) is for payment or health care operations and is not otherwise required by law, and (2) relates to a health care item or service which you paid for in full out of pocket. If we agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.
- C. You have 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.
- D. You have the right to amend your PHI. This means you may request an amendment of your PHI in our records that is contained in a designated record set (e.g., medical and billing records) for as long as we maintain the PHI. We will respond to your request within 60 days (with up to a 30-day extension if needed). We may deny your request if, for example, we determine that your PHI is accurate and complete. If we deny your request, we will send you a written explanation and allow you to submit a written statement of disagreement.
- E. You have the right to receive an accounting of certain disclosures that we have made of your PHI. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right only applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It also excludes disclosures we may have made to you, your family members or friends involved in your care. The right to receive this information is subject to certain exceptions, restrictions and limitations. You must specify a time period for the accounting, which may not be longer than 6 years and cannot include any date before April 14, 2003. You may request a shorter timeframe. You have the right to one free request within any 12-month period, but we may charge you for any additional requests in the same 12-month period. We will notify you about any such charges, and you are free to withdraw or modify your request in writing before any charges are incurred. We will respond to your request within 60 days (with up to a 30-day extension if needed).
- F. You have the right to obtain a paper copy of this Notice from us. You have the right to receive a paper copy of this Notice upon request. You may ask us to give you a copy of this Notice at any time.
- G. You have the right to be notified if you are affected by a breach of unsecured PHI.
- H. You have the right to opt out of receiving fundraising communications from us. We may contact you for fundraising purposes. You have the right to opt out of receiving these communications.
If you believe that we have violated your privacy rights, you may file a complaint with us by notifying our Privacy Officer in writing at the following address: