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.
Andre Bonnett, MD, PC, Sculptology Pleasanton, LLC, and its employees, associates, and consultants are dedicated to maintaining the privacy of your personal health information (“PHI”), as required by applicable federal and state laws. These laws require us to provide you with this Notice of Privacy Practices and to inform you of your rights and our obligations concerning Protected Health Information, or PHI, which is information that identifies you and that relates to your physical or mental health condition. We are required to follow the privacy practices described below while this Notice is in effect.
A. Permitted Disclosures of PHI. We may disclose your PHI for the following reasons:
1. Treatment. We may disclose your PHI to a physician or other health care provider providing treatment to you. For example, we may disclose medical information about you to physicians, nurses, technicians, or personnel who are involved with the administration of your care.
- Payment. We may disclose your PHI to bill and collect payment for the services we provide to you. For example, we may send a bill to you or to a third-party payor for the rendering of services by us. The bill may contain information that identifies you, your diagnosis, and the procedures and supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies, and others that process our health care claims.
- Health Care Operations. We may disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment activities, reviewing the competence or qualifications of healthcare professionals, evaluating provider performance, and other business operations. For example, we may use your PHI to evaluate the performance of the healthcare services you received. We may also provide your PHI to third-party “business associates” (for example, billing or transcription services) or accountants, attorneys, consultants, or others. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- Emergency Treatment. We may disclose your PHI if you require emergency treatment or are unable to communicate with us.
- Family and Friends. We may disclose your PHI to a family member, friend, or any other person who you identify as being involved with your care or payment for care unless you object.
- Required by Law. We may disclose your PHI for law enforcement purposes and as required by state or federal law. For example, the law may require us to report instances of abuse, neglect, or domestic violence; to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness, or missing person. We will inform you or your representative if we disclose your PHI because we believe you are a victim of abuse, neglect, or domestic violence unless we determine that informing you or your representative would place you at risk. In addition, we must provide PHI to comply with an order in a legal or administrative proceeding. Finally, we may be required to provide PHI in response to a subpoena discovery request or other lawful processes, but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI.
- Serious Threat to Health or Safety. We may disclose your PHI if we believe it is necessary to avoid a serious threat to the health and safety of you or the public.
- Public Health. We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury, or disability, or charged with collecting public health data.
- Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative, or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs, and compliance with civil rights laws.
- Not Otherwise Permitted. In any other situation not described in Section A above, we may not disclose your PHI without your written authorization.
- Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment, or healthcare operations activities.
- Marketing and Sale of PHI. We must receive your written authorization for any disclosure of PHI for marketing purposes or for any disclosure which is a sale of PHI. C. Your Rights.
- Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice upon request.
- Right to Access PHI. You have the right to inspect and copy your PHI for as long as we maintain your medical record. You must make a written request for access to your PHI. We may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to state law related to copying medical records. In certain circumstances, we may deny your request to access your PHI, and you may request that we reconsider our denial. Depending on the reason for the denial, another licensed healthcare professional chosen by us may review your request and the denial
- Right to Request Restrictions. You have the right to request a restriction on the use or disclosure of your PHI for the purpose of treatment, payment, or healthcare operations, except in the case of an emergency. You also have the right to request a restriction on the information we disclose to a family member or friend who is involved with your care or the payment of your care. However, we are not legally required to agree to such a restriction.
- Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to us.
- Right to Request Amendment. You have the right to request that we amend your PHI if you believe it is incorrect or incomplete, for as long as we maintain your medical record. We may deny your request to amend if (a) we did not create the PHI, (b) is not information that we maintain, (c) is not information that you are permitted to inspect or copy (such as psychotherapy notes), or (d) we determine that the PHI is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of PHI made by us (other than those made for treatment, payment, or health care operations purposes) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the time period for the accounting.
- Right to Confidential Communications. You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that we call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you.
8. Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured PHI.
D. Changes to this Notice. We reserve the right to change this Notice at any time in accordance with applicable law. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with the revised Notice of Privacy Practices.
E. Acknowledgment of Receipt of Notice. We will ask you to sign an acknowledgment that you received this Notice.
F. Questions and Complaints. If you would like 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 regarding the use, disclosure, or access to your PHI, please contact us. 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 PHI. 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.