Notice of Privacy Practice
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.
The Health Insurance Portability and Accountability Act of 1996 (called “HIPAA”) is a new law that requires that your personal medical information is kept private. Your service provider is also required to give you this notice, so that if he does have any of your personal information, you will know how he may use it, or whether and how he may give your information to anyone else.
Your service provider is already keeping your personal health information private. HIPAA establishes the minimum standards for these protections.
He has the right to use and give out your personal medical information to bill for the cost of your health care.
He may also use your personal medical information when we need this information to make sure that you get quality health care, to provide customer services to you, or to resolve any complaints you may have.
He may use or give out your personal medical information, but only for these reasons:
• If state and federal agencies that have the legal right to see your medical information ask for it. For example, if MediCal wanted to make sure that your service provider is billing MediCal correctly. Or, if your service provider needed the information for its own investigation, such as when we make sure there is no fraud or abuse of MediCal money.
• If we need the information for public health activities (such as reporting outbreaks of serious diseases)
• If a court or another agency orders us to release the information;
• If the information is needed by law enforcement (such as when the information is needed to help locate a missing person).
• For research studies that meet all privacy law requirements (such as research related to the prevention of disease or disability);
• If the information will help to avoid a serious and immediate threat to health or safety or
• If we need the information in order to contact you about new or changed benefits.
Federal law says that your service provider must use and give out your personal medical information:
• If you or someone who has the legal right to act for you asks for the information
• If the federal government asks for it; or
• If some other law requires that your medical information be disclosed.
The law requires that He get your permission, in writing, before it can use or give out your personal medical information for any purpose that is not listed in this notice. You may take back your written permission at any time. However, if you take back your permission it will not affect disclosures your service provider already made based on your earlier permission to use or give out your information.
By law, you have the right to:
• See and get a copy of your personal medical information held by your service provider;
• Have your personal medical information changed if you believe that it is wrong or if information is missing, and if your service provider agrees. If your service provider disagrees, you may have a statement of your disagreement added to your personal medical information.
• Get a list of those who your service provider has shared your personal medical information with.
(The list will not cover your personal health information that was given to you or your personal representative, information that was given out to pay for your health care, or for operations, or information that was given out for law enforcement purposes.).
• Ask your service provider to communicate with you in a particular method or location. (For example, by sending information to a person’s P.O. Box instead of their home address).
• Ask your service provider to limit how your personal medical information is used and given out to pay your claims and to run the program that provides services to you. Please note that your service provider may not be able to agree to your request.
• Get a separate paper copy of this notice.
If you have questions or would like more information about this Notice, please call your service provider’s Privacy Officer.
Guillermo Alvarez, MFT
509 W 10th Street
Antioch, CA 94509
(925) 262-1156
(925) 427-1677 FAX
G@Alvarez-MFT.Com
Your service provider works hard to prevent any harm to you caused by the improper use of your personal medical information by our workforce. You have the right to file a complaint if you believe that a person who works for your
service provider has given out or used your personal medical information improperly. You may file a complaint or report a problem to the Privacy Officer, contact information is listed above.
Filing a complaint will not negatively affect the services you receive from your service provider. If you file a complaint or testify, help with an investigation, a review, a proceeding or a hearing, or if you oppose any act or practices that you believe is unlawful under the HIPAA rules, people who work for your service provider cannot take any other actions against you. If you believe any negative actions have been taken against you because you filed a complaint, please let our Privacy Officer know right away.
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services within 180 days of your discovery of the incident causing your complaint.
By law, your service provider is required to follow the terms in this notice. Your service provider has the right to change the way your personal medical information is used and given out. If your service provider makes any changes, you will get a new notice by mail within 60 days of the change.
The privacy practices listed in this notice are effective April 14, 2003.
