Effective Date: 3/2012
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!
This office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
A nurse obtains treatment information about you and records it in a health record.
During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area.He/she will share the information with such specialist and obtain his/her input.
Example of Use of Your Health Information for Payment Purposes:
We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
The health and billing records we maintain are the physical property of the office/hospital. The information in it, however, belongs to you. You have a right to:
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;
If you want to exercise any of the above rights, please contact the Clinic Manager 661-874-4050 x417 in person, by phone, or in writing, during regular, business hours. She will inform you of the steps that need to be taken to exercise your rights.
The office/hospital is required to:
Maintain the privacy of your health information as required by law;
Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request; and,
Accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Clinic Manager 661-874-4050 x417.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Clinic Manager 661-874-4050 x417.
You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services, Alex M. Azar II , whose street address and phone number are:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W. Washington, D.C. 20201
Toll Free: 1-877-696-6775
We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office/hospital.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
Communication with Family
Organ Procurement Organizations
Food and Drug Administration (FDA)
Abuse & Neglect
For Specialized Governmental Functions
Coroners, Medical Examiners, and Funeral Directors
BARTZ-ALTADONNA COMMUNITY HEALTH CENTER is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org as a business associate of BARTZ-ALTADONNA COMMUNITY HEALTH CENTER OCHIN supplies information technology and related services BARTZ-ALTADONNA COMMUNITY HEALTH CENTER and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your health information may be shared by BARTZ-ALTADONNA COMMUNITY HEALTH CENTER with other OCHIN participants when necessary for health care operations purposes of the organized health care arrangement.
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