Welcome To Our Privacy Policy

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. PLEASE REVIEW IT CAREFULLY.

PURPOSE

This form, Notice of Privacy Practices, presents the information that federal law requires us
to give our patients regarding our privacy practices. We are required by applicable federal and state law
to maintain the privacy of your health information. We are also required to give you this Notice about
our privacy practices, our legal duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect
(August 15, 2011), and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided
such changes are permitted by applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information that we maintain,
including health information we created or received before we made the changes. Before we make a
significant change in our privacy practices, we will change this Notice and make the new Notice available
upon request.
We use and disclose health information about you for treatment, payment, and healthcare operations.
For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider
providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide
to you.

Healthcare Operations: We may use and disclose your health information in connection with our
healthcare operations. Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and
provider performance, conducting training programs, accreditation, certification, licensing or
credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or
healthcare operations, you may give us written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any
time. Your revocation will not affect any use or disclosures permitted by your authorization while it was
in effect. Unless you give us a written authorization, we cannot use or disclose your health information
for any reason except those described in this Notice.

To Your Family and Friends: We may disclose your health information to a family member, friend or
another person to the extent necessary to help with your healthcare or with payment for your healthcare,
but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the
notification of (including identifying or locating) a family member, your personal representative or
another person responsible for your care, of your location, your general condition, or death. If you are
present, then prior to use or disclosure of your health information, we will provide you with an
opportunity to object to such uses or disclosures. In the event of your incapacity or emergency
circumstances, we will disclose health information based on a determination using our professional
judgment disclosing only health information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgment and our experience with common practice to
make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions,
medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization. Required by Law: We may use or disclose your
health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of
other crimes. We may disclose your health information to the extent necessary to avert a serious threat
to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces
personnel under certain circumstances. We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence, and other national security activities.
We may disclose to the correctional institution or law enforcement official having lawful custody of
protected health information of inmate or patient under certain circumstances.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions…
You must make a request in writing to obtain access to your health information. You may obtain a form
to request access by using the contact information listed at the end of this Notice

Disclosure Accounting: You have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than treatment, payment, healthcare
operations and certain other activities.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure
of your health information. We are not required to agree to these additional restrictions, but if we do,
we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your
health information by alternative means or to alternative locations. {You must make your request in
writing.} Your request must specify the alternative means or location, and provide a satisfactory
explanation of how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must
be in writing, and it must explain why the information should be amended.) We may deny your request
under certain circumstances.
Electronic Notice: If you receive this Notice on our website or by electronic mail (e-mail), you are
entitled to receive this notice in written form.
We support your right to the privacy of your health information. If you want more information about
our privacy practices or has questions or concerns, please contact us at 925-218-7005.