Effective Date: April 1, 2003
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.
Understanding your health record
A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examination and test results, diagnoses, treatment, and a plan for future care are recorded. This information is most often referred to as your “health or medical record,” and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professional who may contribute to your care. Understanding what information is retained in your record and how that information may be used will help you to ensure its accuracy, and enable you to relate to who, what, when, where, and why others may be allowed access to your health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others. Use or disclosure of your health information will follow the more stringent of State or Federal laws.
Understanding your health information rights
Your health record is the physical property of the health care practitioner or facility that compiled it but the content is about you, and therefore belongs to you. You have the right to request restrictions on certain uses and disclosures of your information, and to request amendments be made to your health record. Your rights include being able to review or obtain a paper copy of your health information, and to be given an account of all disclosures. You may also request communications of your health information be made by alternative means or to alternative locations. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose your health information.
Our responsibilities: This office is required to maintain the privacy of your health information and to provide you with notice of our legal commitment and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations.
This office reserves the right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will notify you at the current address provided on your medical file. If applicable, this office will post changes on our web site that provides information about our customer service and/or benefits.
Other than for reasons described in this notice, this office agrees not to use or disclose your health information without your authorization.
To receive additional information or report a problem
For further explanation of this notice you may contact Jennifer Hurd at 707-522-6200.
If you believe your privacy rights have been violated, you have the right to file a complaint with this office by contacting the individual above, or by contacting the Secretary of Health and Human Services, with no fear of retaliation by this office.
Your health information will be used for treatment, payment, and health care operations.
Treatment – Information obtained by your health practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your physician recording his/her own expectations and those of others involved in providing you care. The sharing of your health information may progress to others involved in your care, such as specialty physicians or lab technicians.
Payment – Your health care information will be used in order to receive payment for services rendered by this office. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used.
Health Care Operations – The medical staff in this office will use your health information to assess the care you received and the outcome of your case compared to others like it. Your information may be reviewed for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.
Understanding our office policy for specific disclosures
- Business Associates – Some or all of your health information may be subject to disclosure through contracts for services to assist this office in providing health care. For example, it may be necessary to obtain specialized assistance to process certain laboratory tests or radiology images. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.
- Notification – Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well being or your whereabouts.
- Communications with Family – Using best judgment, a family member, or close personal friend, identified by you, may be given information relevant to your care and/or recovery.
- Funeral Directors – Your health information may be disclosed consistent with laws governing mortician services.
- Organ Procurement Organizations – Your health information may be disclosed consistent with laws governing entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation or transplant.
- Marketing – This office reserves the right to contact you with appointment reminders or information about treatment alternatives and other health-related benefits that may be appropriate to you.
- Fund Raising – This office reserves the right to contact you as part of fund-raising efforts.
- Patient Directory (typically applicable only to inpatient settings) – Unless you object, this facility will use your name, room number, general condition, and religious affiliation for directory purposes. This information will be made available to clergy, and others who ask for you by name.
- Research (typically applicable only to inpatient settings) – Your information will be disclosed to researchers upon Institutional Review Board approval, and upon the assurance that established protocol to ensure the privacy of your health information has been obtained.
- Food and Drug Administration (FDA) – This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable product recalls, repairs, or replacements.
- Worker’s Compensation – This office will release information to the extent authorized by law in matters of worker’s compensation.
- Public Health – This office is required by law to disclose health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This office is further required by law to report communicable disease, injury, or disability.
- Correctional Facilities – This office will release medical information on incarcerated individuals to correctional agents or institutions for the necessary welfare of the individual or for the health and safety of other individuals. The rights outlined in this Notice of Privacy Practices will not be extended to incarcerated individuals.
- Law Enforcement – (1) Your health information will be disclosed for law enforcement purposes as required under state law or in response to a valid subpoena. (2) Provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys in the event that a staff member or business associate of this office believes in good faith that there has been unlawful conduct or violations of professional or clinical standards that may endanger one or more patients, workers, or the general public.
NOTICE OF PRIVACY PRACTICES AVAILABILITY: The terms described in this notice will be posted where registration occurs. All individuals receiving care will be given a hard copy.
Bill of Rights
Your Rights and Our Responsibilities
You have a right to:
Considerate and respectful care.
- Obtain your health care professionals and other direct providers of patient care services relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
- Know the identity of your care professionals, and others involved in their care and their credentials, as well as when those care providers are students, residents, or other trainees.
- Know the immediate and long-term financial implications of treatment choices, if known.
- Make decisions about the plan of care prior to and during the course of treatment.
- Refuse a recommended treatment or plan of care to the extent permitted by law and standard operating procedures of the Center and to be informed of the consequences of this action. In case of such refusal, you are entitled to other appropriate care and services that the Center provides or transfer to another provider of health care services. The Center should notify you of any policy that might affect patient choice.
- Have the information contained in your record explained or interpreted as necessary, except where restricted by law.
- Expect that, within its capacity and policies, the Center will, within reason, respond to your request for appropriate health care services. The Center must provide evaluation, service, and/or referral appropriate to your condition. When clinically appropriate and legally permissible, or at your request, your care may be transferred to another health care professional, provided the health care professional has accepted your transfer.
- Ask for and be informed of the existence of business relationships among the Center, manufacturers of products and services, educational institutions, other health care professionals, and/or payers, if any, that might influence your treatment and care.
- Consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. If you decline to participate in research or experimentation, you are entitled to the most effective care that the Center can otherwise provide.
- Expect reasonable continuity of care when appropriate and to be informed by your health care professionals and others participating in your care of available and realistic patient care options when care within the Center is no longer appropriate.
- Be informed of the policies and practices of the Center to relate to your care and the responsibilities of providers of health care services.
- Be informed of available resources for resolving disputes, grievances, and conflicts.
- Be informed of the fees for services provided by your health care professionals and the Center.
The collaborative nature of health care requires that a patient (and their family members/guardian and/or Personal Representative) participate in their care. The effectiveness of care and patient satisfaction depends, in part, on the patient fulfilling certain responsibilities. You are responsible for providing information about past illnesses, hospitalization, medications, and other matters related to your health. To participate effectively in decision-making, you must take responsibility for requesting additional information or clarification about your condition or treatment when you do not fully understand information and/or instructions. You are also responsible for informing your health care professionals if you anticipate problems following the prescribed treatment or post-operative care.
You should be aware of the Center’s obligation to be reasonable, efficient and equitable in proving care to other patients and the community; the Center’s policies and standard operating procedures are designed to fulfill this obligation. You are responsible for making reasonable accommodations for the needs of other patients, the professional staff and employees of the Center. You are responsible for proving necessary information for insurance claims and working with the Center to make payment arrangements, when necessary.
Your vision depends on much more than the health care you receive at the Center. As a result, you are responsible for recognizing the impact of your lifestyle on the health of your eyes and vision.
Changes to this Notice
By law, we must abide by the terms of the Privacy Practices; however, we reserve the right to change our Privacy Practices and/or this Notice. If we revise this Notice, the new Notice will be effective for all the medical information we maintain. Any new Notices will be available by accessing the website, jayb72.sg-host.com, requesting that a copy be sent to you in the mail or asking for a copy at the time of your next appointment or visit.
Your Personal Representative may exercise your rights on your behalf. A Personal Representative may include your guardian if you are a minor, lack decision-making capacity or are legally incompetent, or a person you have authorized to act on your behalf as specified in a written document (such as a power of attorney).
For More Information or to Report a Complaint
If you have questions or would like more information about this notice, you may contact the Privacy Officer at 3540 Mendocino Ave. Suite 200, Santa Rosa, CA 95403.
If you believe your privacy rights have been violated, you may file a written complaint with the Privacy Officer or the Secretary of the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
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