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THIS NOTICE
DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our practice is dedicated, and we are required by applicable federal and
state laws, to maintain the privacy of your health information. These
laws also require us to provide you with this Notice of our privacy practices,
and to inform you of your rights, and our obligations, concerning your
health information. We are required to follow the privacy practices described
below while this Notice is in effect. This Notice is effective as of July
1, 2003 and will remain in effect until we replace it.
CHANGES TO NOTICE:
We reserve the right to change this Notice and the privacy practices described
below at any time in accordance with applicable law. Prior to making significant
changes to our privacy practices, we will alter this Notice to reflect
the changes, and make the revised Notice available to you on request.
Any changes we make to our privacy practices and/or this Notice may be
applicable to health information created or received by us prior to the
date of the changes.
You may request a copy of our Notice at any time. For more information
about our privacy practices, or for additional copies of this Notice,
please contact us using the information listed at the end of this Notice.
PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:
A. TREATMENT, PAYMENT, HEALTH CARE OPERATIONS: You should be aware
that during the course of our relationship with you we will likely use
and disclose health information about you for treatment, payment, and
healthcare operations. Examples of these activities are as follows:
Treatment: We may use or disclose your health information to a physician
or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment
for services we provide to you.
Healthcare Operations: We may use and disclose your health information
in connection with our healthcare operations. Healthcare operations include
quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner
and provider performance, and other business operations.
B. AUTHORIZATIONS: You may specifically authorize us to use your
health information for any purpose or to disclose your health information
to anyone, by submitting such an authorization in writing. Upon receiving
an authorization from you in writing we may use or disclose your health
information in accordance with that authorization. You may revoke an authorization
at any time by notifying us in writing. Your revocation will not affect
any use or disclosures permitted by your authorization while it was in
effect. Unless you give us a written authorization, we cannot use or disclose
your health information for any reason except those permitted by this
Notice.
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must
disclose your health information to you, as described in the Patient Rights
section of this Notice. Such disclosures will be made to any of your personal
representatives appropriately authorized to have access and control of
your health information. We may disclose your health information to a
family member, friend or other person to the extent necessary to help
with your healthcare or with payment for your healthcare only if authorized
to do so. In the event of your incapacity or in emergency circumstances,
we will disclose health information based on a determination using our
professional judgment disclosing only health information that is directly
relevant to the person's involvement in your healthcare.
D. MARKETING: We will not use your health information for marketing
communications without your written authorization. However, our office
needs to leave messages, return telephone calls, and send office mail
to your home address as part of our normal practice. This agreement will
allow our office to use your name and the indicated mailing address for
sending reminders about scheduled appointments, re-activation letters,
sending birthday/holiday cards, office newsletters, or providing information
about other health related matters that may be of interest to you, billing
statements/questions, status of your account, and other office related
matters. We will use your home address unless you indicate a preferred
mailing address. This authorization may be revoked by you at any time,
by advising our office of this revocation in writing.
E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your
health information when we are required to do so by law, including for
public health reasons (e.g., disease reporting). In some instances, and
in accordance with applicable law, we may be required to disclose your
health information to appropriate authorities if we reasonably believe
that you are a possible victim of abuse, neglect, or domestic violence
or the possible victim of other crimes.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, we
may disclose your health information to the extent necessary to avert
a serious threat to your health or safety or the health or safety of others.
G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances
we may disclose health information relating to members of the Armed Forces
to military authorities. Under certain circumstances we may also disclose
health information relating to inmates or patients to correctional institutions
or law enforcement personnel having lawful custody of those individuals.
We may disclose health information in response to judicial proceedings
and law enforcement inquiries as permitted by law and to authorized federal
officials health information required for lawful intelligence, counterintelligence,
and other national security activities.
H. APPOINTMENT REMINDERS: We may use or disclose your health information
to provide you with appointment reminders (such as voicemail messages,
postcards, or letters).
PATIENT RIGHTS:
A. ACCESS TO RECORDS: Upon submission of a written request to us,
you have the right to review or receive copies of your health information,
with limited exceptions. You may obtain a form to request access by using
the contact information listed at the end of this Notice. You may request
that we provide copies in a format other than photocopies and we will
use the format you request if it is readily available. We will charge
you a reasonable cost-based fee relating to the production of such copies.
If you request copies, we will charge you reasonable costs of labor associated
with making copies including no less than twenty-five (25) cents per page
for copies or fifty (50) cents per page from microfilm, and postage if
you want the copies mailed to you, a minimum fee of $25 will apply for
these records. If you request an alternative format, we will charge a
reasonable cost-based fee for providing your health information in that
format. If you prefer, we will prepare a summary or an explanation of
your health information for a fee. If you request a copy of your dates
of service, a minimum $10 fee will apply. Contact us using the information
listed at the end of this Notice if you are interested in receiving a
summary of your information instead of copies. All requests must be in
writing, including requests for records, dates of service, or addendums
to records. A minimum of a $15 fee will apply to any requests to fill
out forms for the Employment Development Department, Unions, Creditors,
or any other disability and/or insurance forms and must include a self-addressed
stamped envelope. All minimum fees are due and payable at time of request.
If additional fees are due, you will be notified at time of receipt of
forms.
B. ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request, you
have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than
treatment, payment, healthcare operations and other activities authorized
by you, for the last 6 years, but not before April 14, 2003. If you request
this accounting more than once in a 12-month period, we may charge you
a reasonable, cost-based fee for responding to these additional requests.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right
to request that we place additional restrictions on our use or disclosure
of your health information for treatment, payment and healthcare operations
purposes. Depending on the circumstances of your request we may, or may
not agree to those restrictions. If we do agree to your requested restrictions
we must abide by those restrictions, except in emergency treatment scenarios.
You have the right to request that we communicate with you about your
health information by alternative means or to alternative locations (e.g.,
at your place of business rather than at your home). Such requests must
be made in writing, must specify the alternative means or location, and
must provide satisfactory explanation how payments will be handled under
the alternative means or location you request.
D. AMENDMENTS TO RECORDS: You have the right to request that we
amend your health information. Such requests must be made in writing,
and must explain why the information should be amended. We may deny your
request under certain circumstances.
E. ELECTRONIC NOTICES. If you receive this Notice on our Web site
or by electronic mail (e-mail), you are entitled to receive this Notice
in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions
or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or
you disagree with a decision we made or any decisions we may make regarding
the use, disclosure, or access to your health information you may complain
to us using the contact information listed below. You also may submit
a written complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file such a complaint upon request.
We support your right to the privacy of your health information. We will
not retaliate in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Human Services.
Please direct any of your questions or complaints to:
Contact: Angelica
Telephone: 925-275-9350
Fax: 925-275-9390
E-mail: atapia@fcghealth.com
Address: FCG- Bay Area Healthcare
PO Box 657
San Ramon, Ca. 94583
Copyright © 2002 Brown Rudnick eSolutions, LLC. All
Rights Reserved
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