Effective date: April 14, 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.
The federal government's Health Insurance Portability and
Accountability Act (HIPAA) regulations define Protected
Health Information as written and oral health information,
including demographic data that can be used to identify you,
that is created or received by your health care provider,
and that relates to your past, present or future physical or
mental health or condition. Our practice has always been
committed to ensuring the privacy of your Protected Health
Information. This document will describe the HIPAA
regulations about protected health information that may be
released without a separate authorization from you and the
protected health information which requires a separate
authorization from you before Protected Health Information
can be released.
USES AND DISCLOSURES THAT DO NOT REQUIRE AN AUTHORIZATION
UNDER THIS NOTICE
Our practice may use and disclose Protected Health
Information to ensure that you receive treatment specific to
your needs. For example, we may use/disclose your Protected
Health Information to another provider, hospital, or nursing
home to coordinate care for your condition.
Our practice may use and disclose your Protected Health
Information to obtain payment for services rendered to you.
For example, we may release diagnosis information to your
insurance company to obtain payment for a hospital or office
visit. Additionally we may release copies of progress
notes, operative reports, or other documentation as required
by your insurance company or medical group. We may also
disclose patient information to another provider involved in
your care for the other provider's payment activities.
HEALTH CARE OPERATIONS:
Our practice may use/disclose your Protected Health
Information to facilitate the business operations of our
practice. For example, we will share your Protected Health
Information with third party business associates who perform
certain business activities for our practice. These
business associates will appropriately safeguard all
Protected Health Information. Additionally we may use your
Protected Health Information for quality assessment and
improvement activities, review and auditing.
AS REQUIRED BY LAW:
Our practice may disclose Protected Health Information about
you to the extent that such use or disclosure is required by
law and the use or disclosure complies with and is limited
to the relevant requirements of such law.
PUBLIC HEALTH ACTIVITIES:
We may disclose Protected Health Information to public
health authorities authorized to receive this information
upon their request or as required by law. Examples of these
disclosures include, but are not limited to the following:
prevention of or controlling disease, injury or disability,
reports of births and deaths, conducting public health
surveillance or investigations or interventions, and the
abuse or neglect of children, elders or dependent adults.
We may also release information to the Food and Drug
Administration (FDA) regarding FDA-regulated products or
activities. Furthermore we may report, as required by law,
persons who have been exposed to a communicable disease or
may be otherwise at risk of spreading a disease or condition.
We may disclose Protected Health Information of an
individual whom we reasonably believe to be a victim of
abuse, neglect, or domestic violence to a government
authority (including a social service or protective services
agency authorized by law to receive reports of such abuse,
neglect, or domestic violence) to the extent the disclosure
is permitted or required by law and to the extent the
disclosure complies with and is limited to the relevant
requirements of such law or if you agree to the disclosure.
We must promptly inform you that such a report has been or
will be made, unless we believe informing you would put you
or others at risk of serious harm.
HEALTH OVERSIGHT ACTIVITIES:
We may disclose Protected Health Information to health
oversight agencies as authorized/required by law including:
audits; civil, administrative or criminal investigations;
inspections, licensure or disciplinary actions; civil,
administrative or criminal proceedings or actions; or other
activities necessary for appropriate oversight.
We may use and disclose Protected Health Information in the
course of any judicial or administrative proceeding in
response to an order of a court or administrative tribunal,
subpoena, discovery request, or other lawful process, if we
receive assurance that reasonable efforts have been made to
give you notice of this request.
LAW ENFORCEMENT PURPOSES:
We may disclose Protected Health Information for law
enforcement purposes to law enforcement officials: in
response to a court order, subpoena, warrant or summons; to
identify and locate a suspect, fugitive, material witness or
missing person; about the victim of a crime; about a death
that may have been caused by criminal activity; about a
crime on our premises; in an emergency; and as otherwise
required by law.
CORONERS AND MEDICAL EXAMINERS:
We may disclose Protected Health Information to a coroner or
medical examiner for the purpose of identifying a deceased
person, determining a cause of death, or other duties as
authorized by law.
We may disclose Protected Health Information to organ
procurement organizations or other entities engaged in the
procurement, banking, or transplantation of cadaveric
organs, eyes, or tissue for the purpose of facilitating
organ, eye or tissue donation and transplantation.
We may use or disclose de-identified Protected Health
Information for research, regardless of the source of the
funding of the research, provided that an Institutional
Review Board or Privacy Board has presented an alteration to
or waiver of an authorization needed for use and disclosure
of Protected Health Information.
SERIOUS THREATS TO HEALTH AND SAFETY:
We may, consistent with applicable law and standards of
ethical conduct, use or disclose Protected Health
Information, if we, in good faith, believe that this use or
disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the
public, or that the disclosure is to a person or persons
reasonably able to prevent or lessen the threat, including
the target of the threat, or that the disclosure is
necessary for law enforcement authorities to identify or
apprehend the suspect.
MILITARY AND VETERANS:
If you are an American or foreign Armed Forces personnel we
may release Protected Health Information as required by
appropriate military command authorities.
NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES:
We may disclose Protected Health Information to authorized
Federal officials for the conduct of lawful intelligence,
counter-intelligence, and other national security activities
authorized by the National Security Act.
PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS:
We may disclose Protected Health Information to authorized
federal officials for the provision of protective services
to the President or other persons, to foreign heads of
state, or for the conduct of investigations.
INMATES AND CORRECTIONAL FACILITIES:
An inmate does not have a right to this Privacy Notice under
the HIPAA Privacy Regulation Text. We may disclose
Protected Health Information to a correctional institution
or law enforcement official having lawful custody of an
inmate, if the Protected Health Information is necessary for
the provision of healthcare to the inmate, the health and
safety of that inmate or others at the correctional facility.
WORK-RELATED ILLNESS OR INJURY:
Our practice may release Protected Health Information that
is relevant to work-related illness or injury.
CALIFORNIA'S CANCER REPORTING SYSTEM:
If you are diagnosed and/or receive treatment for cancer,
your information will be reported to Region 9 of the
California Cancer Registry. All information collected by
the California Cancer Reporting system is subject to strict
FAMILY MEMBERS, OTHER RELATIVES OR CLOSE PERSONAL FRIENDS OR
OTHERS DESIGNATED BY YOU TO BE INVOLVED IN YOUR CARE:
We may disclose to the above people the Protected Health
Information directly relevant to their involvement with your
health care or payment related to your health care. You may
object to these disclosures. If you do not object to these
disclosures or we can infer from the circumstances that you
do not object or we determine, in the exercise of our
professional judgment, that it is in your best interests for
us to make disclosure of information that is directly
relevant to the person's involvement with your care, we may
disclose your Protected Health Information as described.
Our practice may use your Protected Health Information to
notify you in writing or by phone about an appointment for
We may disclose Protected Health Information to a public or
private entity authorized by law or by its charter to assist
in disaster relief efforts.
TREATMENT ALTERNATIVES, HEALTH-RELATED PRODUCTS OR SERVICES:
Our practice may use/disclose your Protected Health
Information to tell you about or recommend possible
YOUR RIGHTS AS A PATIENT UNDER THIS NOTICE:
REQUESTS FOR RESTRICTIONS OF USES AND DISCLOSURES OF YOUR
PROTECTED HEALTH INFORMATION:
You may request, in a written notice to our Privacy Officer,
that our practice restrict the uses and disclosures of your
Protected Health Information for treatment, payment or
health care operations. However, our practice is not
required to agree to your restriction, and, even if we agree
to a restriction today, it may be withdrawn by notifying you
in writing at a later date. Additionally, your request to
restrict the use or disclosure of your Protected Health
Information does not apply to disclosures which are required
by law. Furthermore, the requested restriction (if it is
agreed to) will only affect future releases of information.
Your request must state the specific restriction requested
and to whom you want the restriction to apply. If you wish
to terminate a restriction on release of your Protected
Health Information, it must be done in writing. Requests
must be made in writing to our Privacy Officer.
REQUESTS FOR COMMUNICATIONS OF PROTECTED HEALTH INFORMATION
BY ALTERNATIVE MEANS OR AT ALTERNATE LOCATIONS:
If you wish to receive information from our practice at a
location other than the home address provided on your
Patient Information Sheet or by a certain method or means,
you must complete a written request, and provide complete
address information. We will not require you to provide an
explanation for your request. Requests must be made in
writing to our Privacy Officer. We will accommodate all
requests where it is reasonable to do so.
INSPECT AND OBTAIN A COPY OF PROTECTED HEALTH INFORMATION:
You have the right to inspect and to have copies of your
Protected Health Information except for psychotherapy notes;
information compiled in reasonable anticipation of, or for
use in, a civil, criminal or administrative action or
proceeding; certain types of research information while the
research is in progress; and other information which is
restricted for other reasons. We will charge you a fee for
the costs incurred by us in complying with your request.
Your request to review and/or have copies of your Protected
Health Information must be in writing and be submitted to
our Privacy Officer. In very rare instances your request to
inspect and to have copies of your Protected Health
Information may be denied or limited. In this case, you
have the right to appeal the decision and to a review of the
decision by another licensed health care professional. The
decisions made will comply with the guidelines provided in
the HIPAA legislation. Requests must be made in writing to
our Privacy Officer.
REQUEST AN AMENDMENT TO PROTECTED HEALTH INFORMATION:
You may request an amendment of Protected Health Information
about you in a designated record set for as long as we
maintain this information. Your request must be in writing,
must be addressed to our Privacy Officer and must define the
reasons to support your request. We have up to 60 days to
review your request and to determine if the requested
amendment will be made. You will be notified in writing
about the acceptance or denial of your request. If your
request for an amendment is agreed to, the amendment will be
made to your record and reasonable efforts will be made to
notify those persons you identify as needing to have copies
of the amendment.
If your request for an amendment to your Protected Health
Information is denied, you may submit a written statement
not to exceed 250 words disagreeing with the denial which
will be kept as a part of your Protected Health Information
and may be released with other Protected Health Information
upon your written request.
ACCOUNTING OF DISCLOSURES:
You have the right to make a written request for a list of
certain disclosures of your medical information by our
practice for purposes other than treatment, payment or
health care operations. Your written request must be
submitted to our Privacy Officer, and it must specify the
time period requested for the accounting. You may request
an accounting of information released for up to a 6-year
period, but this period may not begin prior to April 14,
2003. We have up to 60 days to provide you with the
requested accounting. If we are unable to comply, within
this time, we will extend it by no more than 30 days. We
will provide the first accounting during any 12-month period
without charge. Subsequent accounting requests may be
subject to a reasonable cost-based fee.
COPIES OF THIS NOTICE:
You have the right to receive a paper copy of this notice,
even if you first received this notice electronically. Our
Privacy Notice is also posted prominently in our office.
This Privacy Notice is available to anyone upon request.
Please contact our Privacy Officer for additional copies of
RIGHT TO FILE A COMPLAINT:
If you have a complaint about the manner in which your
Protected Health Information has been managed, you may
complain in writing to our Privacy Officer and to the
Secretary of Health and Human Services. You will not be
retaliated against for filing a complaint. Information
regarding matters covered by this Notice can be requested by
contacting the Privacy Officer. Written complaints against
the provider can be mailed to the Privacy Officer at the
USES AND DISCLOSURES THAT REQUIRE AN AUTHORIZATION
UNDER THIS NOTICE:
OTHER USES AND DISCLOSURES REQUIRING AN AUTHORIZATION:
Other uses and disclosures of Protected Health Information
will be made only with your written authorization. Our use
or disclosure must be consistent with an authorization
obtained for that purpose. You may revoke your
authorization in writing at any time. If you revoke your
authorization, we will no longer disclose medical
information restricted in your authorization. However, you
must understand that any information previously released
under your authorization, cannot be taken back.
OUR REQUIREMENTS AS A COVERED ENTITY UNDER THIS NOTICE:
REVISIONS TO THIS NOTICE:
We reserve the right to change this notice. 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. We are required to
promptly revise, post, and distribute our notice whenever
there is a material change to the uses or disclosures,
individual patient rights, our legal duties, or other
privacy practices stated in the notice. Except when
required by law, a material change to any term of the notice
may not be implemented prior to the effective date of the
notice in which such material change is reflected. Our
provisions currently in effect.
For further information or questions about this notice and
any of our privacy practices, please contact our Privacy
Officer at the address and phone listed below:
Michael Gottlieb, M.D.
1320 El Capitan Drive #440
Danville, CA 94526
RECEIPT OF PRIVACY NOTICE
Your signature below states that you have received a copy of
our practice's privacy notice. This acknowledgement will be
kept in your chart.
Signature of Patient or Personal Representative
Date of Birth
Personal Representative's relationship to the patient:
Copyright © 2005-2017 Michael M. Gottlieb, M.D.
Michael M. Gottlieb, M.D., F.A.C.S.