If this is an emergency or you need immediate help, please call 9-1-1.
This notice describes how medical information about you may be used and disclosed and how you can get access to it.
Please read carefully.
SECTION 1:
Your medical records are used to provide treatment, bill and receive payments, and conduct healthcare operations. Examples of these activities include but are not limited to review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal used outlined above except required by law or authorized by the patient or legal representative.
SECTION 2:
Federal and State laws require abuse, neglect, domestic violence, and threats to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure further increases risks.
SECTION 3:
Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2.
SECTION 4:
You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want to be disclosed, the name and address of the entity you want the information released to, the purpose, and the expiration date of the authorization. Any authorization provided may be revoked in writing at any time. Psychotherapy notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records are stored oS-site.
SECTION 5:
You may request corrections to your records.
SECTION 6:
A request for disclosure may be denied under the following circumstances: the disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.
SECTION 7:
If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request a review of the denial. A review will be conducted by another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.
SECTION 8:
You may request that we restrict uses and disclosures outlined in Section 1.
However, we are not required to agree to the restrictions. If an agreement is made to
restrict use or disclosure, we will be bound by such restriction until revoked by you or your
legal representative orally or in writing except when disclosure is required by law or in an
emergency. We may also revoke such restrictions but information gathered while required
by law or in an emergency. We may also revoke such restrictions but information gathered
while the restriction was in place will remain restricted by such an agreement.
This
agreement may be modified or amended as required by law or in the course of health care
operations.
The new notice will be available upon request. You may, at any time, request a full detailed version by asking me and I will provide you with one promptly ESective Date: This Notice is eSective as of September 23, 2013. If you believe your privacy rights have been violated, you may file a complaint with Dr. Jose L Guerra, at drjose@drjoseguerra.com or 818- 770- 6147. You may also file a written complaint with the Director, OSice for Civil Rights of the U.S. Department of Health and Human Services. Upon request, you will be provided with the current address for the Director. You will not be penalized for filing a complaint.