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Office Policies/Agreement
Patient Consent to Notice of Privacy Practices In Accordance with the Health Insurance Portability and Accountability Act (HIPAA), you have been provided with our Notice of Privacy Practices that provides information about how we may use and disclose protected health information (“PHI”) about you. The notice provides a more complete description of information uses and disclosures.
As part of your healthcare, we maintain health records that describe your health history, symptoms, examinations and test results, diagnosis, treatment and plans for future care or treatment. This information serves as a basis for planning your care and treatment; a means of communication among other health professionals who contribute to your care; a source of information for applying your diagnosis and healthcare information to bill third parties; a means by which a third-party payer can verify that services billed were actually provided; and a toll for routine healthcare operations such as assessing quality and reviewing the delivery of medical services.
You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice and/or privacy practices may change. If we change our notice and/or privacy practices, we will provide you with a revised copy by mailing it to your then-current address.
You have the right to object to the use of disclosure of your health information. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and disclosure of PHI about you for treatment, payment and health care operations in accordance with the notice of privacy practices. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
I request the following restrictions to the use or disclosure of my health information:
You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice and/or privacy practices may change. If we change our notice and/or privacy practices, we will provide you with a revised copy by mailing it to your current address on file.
Notice of Patient Individual Rights Pursuant to the health Insurance Portability and Accountability Act (“HIPAA”), this notice to you that with respect to your medical and health care records at this office, you have the following rights:
1. RIGHT TO ACCESS AND COPY INFORMATION.
In Accordance with 45 C.F.R. §164.524, you have the right to access and copy your own protected health information (“PHI”) maintained in “designated record sets”. A designated record set includes your medical records and billing records maintained in this office.
Our office is required to respond to your request for access and/ or copying of your records within 30 days following receipt of a written request from you. If your records are not accessible on site in the office, we are required to respond within 60 days. If for some reason we deny your request to access or copy your records, you may appeal that denial to the contact person/privacy officer at this office, whose name, phone number and address is listed below
You may be charged a reasonable fee for costs associated with the copying of your records. These costs typically will be ten cents ($0.10) per page for standard reproduction of documents of a size 8 1⁄2 by 14 inches or less and reasonable clerical costs incurred in locating and making the records available to be billed at the maximum rate of sixteen dollars ($16.00) per hour per person, computed on the basis of four dollars ($4.00) per quarter hour or fraction thereof and actual postage charges
2. RIGHT TO AMEND INFORMATION.
In accordance with 45 C.F.R. §164.526, you have the right to amend erroneous or incomplete PHI, unless the information was not created by our office, or the information is not in a “designated record set”, or is accurate and complete, or would not be available for inspection under the previous section.
Our office is required to respond within 60 days, following receipt of a written request from you, by granting or denying your request. If we deny your request, you may file a statement of disagreement which will be included in your records.
If you grant your request to amend the records, we will make the correction in all affected records, inform our business associates and others regarding the correction as needed and we will inform you when the correction has been made.
Any corrections that may be made will conform to the medical practice model for amending medical records in order to retain the integrity of the original entry but append the correction.
3. RIGHT TO OBTAIN ACCOUNTING OF DISCLOSURES
In accordance with 45 C.F.R. §164.528, you have the right to obtain an “accounting” of disclosures of your PHI made within six years before the request, starting from the effective date of April 14, 2003. The accounting shall include disclosures of your PHI made by both our office and our business associates and shall include the date, receipt name and address, description of the information disclosed, and the purpose of the disclosure.
Our office is required to respond within 60 days following a receipt of a written request from you. Disclosures exempt from the accounting requirement include those: a. to carry out treatment, payment or health care operations; b. to you or your personal representatives; c. for incidental purposes such as the office sign-in sheet; d. to family members and others involved in your care; e. for national security or intelligence purposes; and f. correctional institutions and other law enforcement agencies under the custodial exception.
4. RIGHT TO REQUEST RESTRICTION OF USE OR DISCLOSURE
In accordance with 45 C.F.R. §164.522(a), you have the right to request restrictions on how our office will use or disclose your PHI for treatment, payment, or health care operations and how your information will be disclosed to family members or others involved in your care. Our office is not required to agree to such restriction.
However, if we agree, then we are obligated to comply with that agreement unless the information is required for an emergency, or is requested for law enforcement, judicial and administrative proceedings or research.
5. RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATION.
In accordance with §164.522 (b), we will accommodate reasonable request from you to receive communications of your PHI by alternative means or at alternative locations. For example, you may request our office not to send certain medical information to your home, so that a family member cannot access that information.
6. RIGHT TO RECEIVE NOTICE OF PRIVACY PRACTICES
In accordance with 45 C.F.R. §164.520, you have the right to receive a notice of our office’s privacy practices that describe the uses and disclosures of PHI, you rights under the Privacy Standards and our legal duties regarding PHI. We are required to inform you of your right to complain to our office or the Department of Health and Human Services (DHSS) Secretary, if you believe that your privacy rights have been violated. If you have any questions or if you wish to register a complaint, the person to contact is the contact person/privacy officer at this office, whose name, phone number and address are listed below.
- Jody Stanley
- 8750 Wilshire Blvd. Suite 210 Beverly Hills, CA 90211
- Phone: 310-652-0920
The notice referred to in the preceding paragraph will be in plain language. Our office reserves the right to change its privacy practice in its privacy notice, but we will first publish a revised notice prior to any change in practices. Our office will provide its notice to patients upon request, at first service and on our website if a website is available.
Any corrections that may be made will conform to the medical practice model for amending medical records in order to retain the integrity of the original entry but append the correction.
7. RIGHT TO CONSENT TO OR AUTHORIZE CERTAIN USES AND DISCLOSURES.
As discussed in the section on uses and disclosures of PHI, infra, certain uses or disclosures will require your permission, whether consent, authorization or advance notice with an opportunity to object. In each of these circumstances, you have the right to grant or withhold that permission
8. RIGHT TO COMPLAIN OF PRIVACY VIOLATIONS.
You have the right to complain if your privacy rights have been violated. You may complain to the contact person/privacy officer at this office, whose name, phone number and address are listed below. You may also complain to the DHSS Secretary through the Office of Civil Rights at 1-866-627-7748.
We cannot require that you waive this right as a condition for providing treatment, payment or other services and cannot retaliate against you for lodging a complaint with the Secretary.
Notice of Privacy Practices In accordance with the health insurance portability and accountability act (HIPPA), this notice describes how medical information abput you may be used and disclosed and how you can get access to this information. Please review it carefully
If you have any questions about this notice, please contact our Privacy Officer at 8750 Wilshire Blvd., Suite 210, Beverly Hills, CA 90211
A.WHO WILL FOLLOW THIS NOTICE
This notice describes the privacy practices relating to protected health information (“PHI”) followed by the doctors and all of the employees and staff. The doctors, the office employees and staff may share your medical information with each other for treatment, payment of health care operations purposes described in this notice.
B.UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION
Each time you visit a physician, hospital or other healthcare provider, a record of your visit is typically made. This record generally contains your symptoms, examinations and test results, diagnosis, treatment and plan for future care or treatment. This information serves as a basis for planning your care and treatment; a means of communication among the doctors and other healthcare providers that are involved in your care; a medicallegal document describing the care you have received; a means by which you or a third-party can verify that services billed were actually provided; a source of data for medical research, education and data collection; a source of information for public health officials charged with improving community health and other healthcare operations
4. RIGHT TO REQUEST RESTRICTION OF USE OR DISCLOSURE
In accordance with 45 C.F.R. §164.522(a), you have the right to request restrictions on how our office will use or disclose your PHI for treatment, payment, or health care operations and how your information will be disclosed to family members or others involved in your care. Our office is not required to agree to such restriction.
However, if we agree, then we are obligated to comply with that agreement unless the information is required for an emergency, or is requested for law enforcement, judicial and administrative proceedings or research.
C.OUR POLICY REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health (“PHI”) is personal. Our commitment to you is to protect medical information about you. Our office creates a record describing the care and services you receive at our office. This record is necessary in order to provide medical care to you and to comply with certain legal requirements. This notice applies to all of the records created in our office in connection with your care and treatment, whether made by the doctor and/or the employees and staff.
We may be sending automated SMS text/email reminders about your upcoming appointments. If this is a problem for you please notify us. Please update us with your contact information, including your phone number regularly. We will only be sending you generic reminders, which include:
- Patient first name
- Appointment date and time
- Provider first and last name
- Location of the appointment
