(as required by the Health Insurance Portability and Accountability Act of 1996, HIPAA)





Understanding Your Health Record/Information


Each time you visit a provider, a record of your visit is made. Typically, this visit contains your diagnosis, assessment, treatment recommendation and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

v       Basis for planning your care and treatment.

v       Means of communication among the many health professionals who contribute to your care.

v       Legal document describing the care you received.

v       Means by which you or a third-party payer can verify that services billed were actually provided.

v       A tool in educating health professionals.

v       A source of data for medical research.

v       A source of information for public health officials who oversee the delivery of health care in the United States.

v       A tool with which I can assess and continually work to improve the care I render and the outcomes I achieve.


Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.


My Responsibilities

I am required to:

·        Maintain the privacy of your health information.

·        Provide you with a Notice as to our legal duties and privacy practices with respect to information I collect and maintain about you.

·        Abide by the terms of this Notice.

·        Notify you if I are unable to agree to a requested restriction.

·        Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.


I reserve the right to change my practices and to make new provisions effective for all protected health information I maintain. Should my information practices change, I will make available a revised notice. Each time you visit my practice, you may request a copy of the current notice in effect.


How I Will Use or Disclose Your Health Information

v       Treatment: I will use your health information for treatment. For example, I will speak to your dentist to get information to determine the method of sedation that should work best for you. I will also provide your dentist and/or a subsequent healthcare provider with a copy of the anesthesia record and health summary in order to assist him/her in treating you if you need sedation again.


v       Payment: I will use your health information for payment from a third party payer you designate. The information on or accompanying the bill will be limited to that information necessary to establish the claims for which reimbursement is sought. For example, the bill may include information of the dates, types and costs of therapies and services, and a general description of the general purpose of each treatment session or service.


v       Health care operations: I will use your health information for regular operations. For example, I may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the services I provide.


v       Business Associates: There are some services provided in my organization through contracts with business associates. Examples include my accountants, billing consultants, and attorneys. When these services are contracted, I may disclose your health information to my business associates so that they can perform the job I have asked them to do. To protect your health information however, I require the business associates to appropriately safeguard your information.


v       Notification: Using my professional judgment, I may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition.


v       Communication with family: With your written permission, I may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that personšs involvement in your care or payment related to your care.


v       Food and Drug Administration (FDA): I may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements.


v       Workers compensation: I may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.


v       Public health: As required by law, I may disclose your health information without your consent to public health or legal authorities charged with preventing or controlling disease, injury, or disability.


v       Correctional institutions: Should you be an inmate of a correctional institution, I may disclose to the health care professionals at the institution health information necessary for your health treatment.


v       Reports: Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that I have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering individuals, workers or the public.


Your Health Information Rights

Although your health record is the physical property of the provider of service, the information in your health record belongs to you. You have the following rights:

v       You may request that I not use or disclose your health information for a particular reason related to treatment, payment, or general health care operations, and/or to a personal representative or guardian. We ask that such request be made in writing. Although I will consider your request, please be aware that I are under no obligation to accept or abide by it

v       You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. If you request copies I will charge you a reasonable fee.

v       If you believe that any health information in your record is incorrect or if you believe that important information is missing, you may request that I correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment.

v       You may request that I provide you with a written accounting of all disclosures made by me during the time period for which you request (not to exceed six (6) years). I ask that such requests be made in writing. You will not be charged for your first accounting request in any 12 month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee. Please note that an accounting will not apply to any of the following types of disclosures:

·      Disclosures made to you or your legal representative, or any other individual involved with your care.

·      Disclosures made for reasons of treatment, payment or health care operations.

·      Disclosures to correctional institutions or law enforcement officials.

·      Disclosures for national security purposes.


v       You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.

v       You may revoke an authorization to use or disclose health information, except to the extent that action has already been taken. Such a request must be made in writing.


More Information or to Report a Problem

If you have questions about privacy, you may contact me at 906 El Cajon Way, Palo Alto, CA 94303 or by Phone: (650) 856-7819

If you believe that your privacy rights have been violated, you may file a complaint with me. These complaints must be filed in writing. You may also file a complaint with the Secretary of the Federal Department of Health and Human Services. There will be no retaliation for filing a complaint.



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