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.
Tenth Street Pediatric Medical Group, Inc., operating as a health care provider,
which is composed of physicians and other licensed health care professionals
seeing and treating patients at Tenth Street Pediatric Medical Group,
Inc., uses health information about you for treatment, to obtain payment
for treatment, for administrative purposes, and to evaluate the quality
of care that you receive. Your health information is contained in a
medical record that is the physical property of our practice.
OUR COMMITMENT TO SAFEGUARD YOUR MEDICAL INFORMATION
We are committed to protecting the privacy of medical information about you. This includes:
- Information that can be used to identify you that we create or receive about your
past, present, or future health or condition, the provision of health
care to you, or the payment of this health care.
- We are required by law to maintain the privacy of your medical information
and we must provide you with this Notice about our privacy practices
that explains how, when, and why we use and disclose medical information
about you.
- With some exceptions, we may not use or disclose any more of your medical
information than is necessary to accomplish the purpose of the use
or disclosure. We are legally required to follow the privacy practices
that are described in this Notice.
This Notice will tell you about the ways in which we may use and disclose medical
information about you. We also describe your rights and certain obligations
we have regarding the use and disclosure of medical information.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
Uses and Disclosures Without Authorization
The following categories describe different ways that we are permitted to use and
disclose your medical information without a specific authorization from
you.
For Treatment
- We may use medical information about you to provide you with medical
treatment or services.
- We may disclose medical information about you to physicians, nurses,
medical students, and other health care personnel who provide you
with health care services or are involved in your care.
- In addition, many of the people who work for our practice — including,
but not limited to, our doctors and nurses — may use or disclose
your medical information in order to treat you or to assist others
in your treatment.
- We may disclose medical information about you to other health care providers
who request such information for purposes of providing medical treatment
to you.
For Payment
- We may use and disclose medical information about you in order to bill
and collect payment for the treatment and services provided to you.
- We may also contact your insurance company to obtain prior approval for
a treatment you are going to receive or to determine whether it is
covered by your plan.
- We also may use and disclose your medical information to obtain payment
from third parties that may be responsible for such costs, such as
family members.
- We may use your medical information to bill you directly for services
and items.
- We may provide information about you to other health care providers that
have treated you or provided services to you to assist them in obtaining
payment.
For Health Care Operations
- We may use and disclose medical information about you to operate our
business. These uses and disclosures are necessary to operate Tenth
Street Pediatric Medical Group, Inc. and make sure that all of our
patients receive quality care.
- We may disclose medical information about you to another health care
provider or health plan with which you also have a relationship for
such things as quality assurance and case management.
- We may provide medical information about you to our business associates,
such as accountants, attorneys, consultants, and others in order to
make sure we're complying with the laws that affect us. We require
these business associates to appropriately safeguard the privacy of
your information.
Appointment reminders and services
- We may use and disclose medical infor-mation to provide appointment reminders
or test results.
Health-related products and services
We may use and disclose medical information to tell you about health-related
benefits or services that may be of interest to you or necessary for
your treatment.
As required by law:
- We will disclose medical information about you when required by federal,
state, or local law. For example, our practice may disclose information
for the following purposes:
- For judicial and administrative proceedings pursuant to legal authority
- To report information related to victims of abuse, neglect or domestic violence
- To assist law enforcement officials in their law enforcement duties
- To report reactions to medications or problems with products
- To notify people of recalls of products they may be using
- To avert a serious threat to health or safety
- We may use and disclose medical information about you when necessary
to prevent a serious threat to your health and safety or the health
and safety of the public or another person. Any disclosure, however,
would only be to someone able to help prevent the threat or lessen
such harm.
Lawsuits and disputes
- If you are involved in a lawsuit or a dispute, we may disclose medical
information about you in response to a court or administrative order.
- We may disclose medical information about you in response to a court
or administrative ordered subpoena or discovery request, but only
after efforts have been made to tell you about the request.
Public health activities
- Your health information may be used or disclosed for public health activities
such as assisting public health authorities or other legal authorities
to prevent or control disease, injury or disability, or for other
health oversight activities.
Decedents
- Health information may be disclosed to funeral directors or coroners to enable
them to carry out their lawful duties.
Organ and tissue donation
- Your health information may be used or disclosed for cadaver organ, eye
or tissue donation purposes.
Minors
- We may release medical information about minors to their parents or legal
guardians. However, in instances where California law allows minors
to consent to their own treatment without parental consent (i.e.,
HIV testing), information will not be released to a minor’s
parents without the minor's consent unless otherwise specifically
allowed under California law.
Government Functions
- Your health information may be disclosed for specialized government functions
such as protection of public officials or reporting to various branches
of the armed services.
Other Uses
Other uses and disclosures will be made only with your written authorization
and you may revoke the authorization except to the extent our practice
has taken action in reliance on such.
Uses and Disclosures Requiring Authorization
The following categories describe different ways that we are permitted to
use and disclose your medical information only with a specific authorization
from you.
Other Uses and Disclosures of Medical Information
- Other uses and disclosures of medical information not covered by this Notice
or the laws that apply to us will be made only with written permission.
- If you provide us permis-sion to use or disclose medical information
about you, you may revoke that permission, in writing, at any time.
- If you revoke your permission, we will no longer use or disclose medical
information about you for the reasons covered by your written authorization;
however, we cannot take back any disclosures we have already made
based upon your prior permission.
Marketing activities
- We may not use medical information about you to contact you to encourage
you to buy a product or service, which is unrelated to your current
care management except with your specific authorization.
Alcohol and Drug Abuse Patient Records
- Use and disclosure of any medical information about you relative to alcohol
or drug abuse programs, is protected by federal law and regulations.
Generally, we may not say to a person outside the program that you
are or have attended the program, or disclose any information identifying
you as an alcohol or drug abuser unless: (i) you have consented in
writing; (ii) we receive a court order requiring the disclosure; or
(iii) the disclosure is made to medical personnel in a medical emergency
or to qualified personnel for research, audit, or program evaluation.
HIV/AIDS Information
- Use and disclosure of any medical information about you relative to HIV
testing, HIV status, or AIDS, is protected by federal and state law.
Generally, an authorization must be obtained for the disclosure of
such information; however, state law may allow for disclosure of information
for public health purposes.
YOUR HEALTH INFORMATION RIGHTS
You have the right to:
- Request a restriction on certain uses and disclosures or your information
as provided by 45 C.F.R. §164.522; however, our practice is not
required to agree to a requested restriction
- Inspect and obtain a copy of your health record as provided for in 45 C.F.R. §164.524
- Request that your health record be amended as provided in 45 C.F.R. §164.526
- Request communications of your health information by alternative means or at alternative locations
- Receive an accounting of disclosures made of your health information, other
than disclosures of treatment, payment, standard operational procedures,
or appointments as provided by 45 C.F.R. §164.528
- Obtain a paper copy of the notice of information practices upon request
COMPLAINTS
If you believe that we may have violated your rights with respect to your medical
infor-ma-tion, you may file a written complaint with the person listed
in Contact Information below. You also may send a written complaint
to the Office for Civil Rights, U.S. Department of Health and Human
Services, 200 Independence Avenue S.W., Room 515F, HHH Building, Washington,
D.C. 20201 within 180 days of an alleged violation of your rights. You
will not be penalized for filing a complaint about our privacy practices.
You will not be required to waive this right as a condition of treatment.
CONTACT INFORMATION
If you have any questions about this Notice or wish to make a complaint about
our privacy practices, please contact Grace Perez at (310) 458-1714
or via e-mail at .
Written requests or complaints should be sent to this person at 1450
10th Street, #304, Santa Monica, CA 90401.
OBLIGATIONS OF OUR PRACTICE
Our practice is required by law to:
- Maintain the privacy of protected health information
- Provide you with this notice of its legal duties and privacy practices with respect to your health information
- Abide by the terms of this notice
- Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed
- Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations
We reserve the right to make the revised or changed Notice effective for medical
information we already have about you as well as any information we
receive in the future. Before we make an important change to our policies,
we will promptly change this Notice and post a new Notice in Tenth Street
Pediatric Medical Group, Inc. The Notice will contain on the first page,
in the top right-hand corner, the effective date. You can also request
a copy of this Notice from the contact person listed in Contact Information
above at any time or can view a copy of the Notice on our website at
http://www.tenthstpeds.com.
ACKNOWLEDGEMENT
You will be asked to sign an acknowledgement of your receipt of this Notice of
Privacy Practices. We are required by law to make a good faith effort
to provide you with our Notice of Privacy Practices and obtain such
acknowledgement from you. However, your receipt of care and treatment
from Tenth Street Pediatric Medical Group, Inc. is not conditioned upon
your providing the written acknowledgement.
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