HIPPA

As required by the privacy regulations created as a result of the Health Insurance. Portability and Accountability Act of 1996  
(HIPAA).

This notice describes how health information about you (as a patient of this practice) may be used and  
disclosed and how you can get access to your individually identifiable health information.

Please review this notice carefully.

A. Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected  
health information, or PHI). In conducting our business, we will create records regarding you and the treatment and  
services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you.  
We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in  
our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that  
we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI,
• Your privacy rights in your PHI,
• Our obligations concerning the use and dtsclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice.  
We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this  
notice will be effective for all of your records that our practice has created or maintained in the past, and for  
any of your records that we may create or maintain in the future. Our practice will post a copy of our current  
Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice  
at any time.

B. If you have questions about this Notice, please contact:

Office Manager at (619) 222-5433.

C. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as  
blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a  
prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people  
who work for our practice - including, but not limited to, our doctors and nurses - may use or disclose your PHI in order to  
treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your  
care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for  
purposes related to your treatment.

2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you  
may receive from us. For example; we may contact your health insurer to certify that you are eligible for benefits (and for  
what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer  
will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may  
be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items.  
We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways  
in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality  
of care you received from us, or to conduct cost-management and business planning activities for our practice. We may  
disclose your PHI to other health care providers and entities to assist in their health care operations.

4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an  
appointment.

5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or  
alternatives.

6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related  
benefits or services that may be of interest to you.

7. Release of information to family and friends. Our practice may release your PHI to a friend or family member that is  
involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a baby sitter  
take their child to the pediatrician's office for treatment of a cold. In this example, the baby sitter may have access to this  
child's medical information.

S. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal,  
state or local law.  

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect  
information for the purpose of:

• Maintaining vital records, such as births and deaths,
• Reporting child abuse or neglect,
• Preventing or controlling disease, injury or disability,
• Notifying a person regarding potential exposure to a communicable disease,

       *  Notifying a person regarding a potential risk for spreading or contracting a disease or condition,

• Reporting reactions to drugs or problems with products or devices,
• Notifying individuals if a product or device they may be using has been recalled,
• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an  
  adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are  
  required or authorized by law to disclose this information,

      *  Notifying your employer under limited circumstances related primarily to workptace injury or illness or medical

surveillance.

2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized  
by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary  
actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor·  
government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or  
administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a  
discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an  
effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement,
• Concerning a death we believe has resulted from criminal conduct,
• Regarding criminal conduct at our offices,
• In response to a warrant, summons, court order, subpoena or similar legal process,
• To identify/locate a suspect, material witness, fugitive or missing person,
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or  
  location of the perpetrator).

5. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or  
to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their  
jobs.

6. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue  
procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and  
transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will  
obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy  
Board has determined that the waiver of your authorization satisfies all of the following conditions:

  (A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate  
plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the  
earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers  
or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or  
disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for  
other research for which the use or disclosure would otherwise be permitted;

(B) The research could not practicably be conducted without the waiver,

(C) The research could not practicably be conducted without access to and use of the PHI.

8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or  
prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these  
circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Our practice may disclose your PHI if you are a member of U.s. or foreign military forces (including veterans)  
and if required by the appropriate authorities.

10. National security. Our practice may disclose your PHI to federal officials for intelligence and national security  
activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We  
also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to  
conduct investigations.

11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an  
inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the  
institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your  
health and safety or the health and safety of other individuals.

12. Workers' compensation. Our practice may release your PHI for workers' compensation and similar programs.  
E. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

1. Confidential Communications You have the right to request that our practice communicate With you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at  
home, rather than work. In order to request a type of confidential communication, you must make a written request to  
Office Manager at             (619) 222-5433       specifying the requested method of contact, or the location where you wish to be  
contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment,  
payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to  
only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not  
required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise  
required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our  
use or disclosure of your PHI, you must make your request in writing to Office Manager at             (619) 222-5433      . Your  
request must describe in a clear and concise fashion:

• The information you wish restricted,
• Whether you are requesting to limit our practice's use, disclosure or both,
• To whom you want the limits to apply.

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions  
about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit  
your request in writing to Office Manager at             (619) 222-5433       in order to inspect and/or obtain a copy of your PHI. Our  
practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice  
may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our  
denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may  
request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request  
MUST be made in writing and submitted to Office Manager at             (619) 222-5433      . You must provide us with a reason that  
supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason  
supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our  
opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you  
would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the  
information is not available to amend the information.

5. Accounting of disclosures. All of our patients have the right to request an "accounting of disclosures." An "accounting  
of. disclosures" is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to  
treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be  
documented - for example, the doctor sharing information with the nurse; or the billing department using your information  
to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to  
Office Manager at             (619) 222-5433      . All requests for an "accounting of disclosures" must state a time period, which  
may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first  
list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the  
same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw  
your request before you incur any costs.

6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You  
may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Office Manager  
at             (619)222-5433      .

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our  
practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice,

'contact Office Manager at (619) 222-5433. All complaints must be submitted in writing. You will not be penalized for  
filing a complaint.

8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written  
authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization  
you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke  
your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note.  
we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Office Manager             (619)222-5433