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NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
Health Insurance Portability and Accountability Act
of 1996 (HIPAA)
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.
Family Planning Specialists Medical Group, Inc. (FPS) is committed
to protecting the privacy of your health record and the confidentiality
of your visit. Your healthcare record, known as a chart, and the information
it contains will not be disclosed to any one or any agency outside
of FPS without written authorization from you unless such a release
is required by law.
FPS will use your health information for the purpose of:
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Treatment
For example, information obtained by a healthcare provider or
staff member will be recorded in your record and used to determine
the best course of treatment for you. |
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Payment
For example, a bill may be sent to you or to a third party payer.
The information on the bill may include information that identifies
you, as well as your diagnosis, procedure, and supplies used. |
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Regular
Healthcare Operations
For example, members of the medical staff or the quality improvement/risk
management staff may use information in your health record to
assess the care you received and outcomes of your care. This
information will then be used in the Continuous Quality Improvement
program of FPS. |
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Business
Associates
FPS provides some services through contracts with business associates.
An example is a laboratory. To protect your health information,
however, we require the business associate to appropriately
safeguard your information. |
Disclosures required by law:
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Food and
Drug Administration (FDA)
As required by law, FPS may disclose to the Food and Drug Administration
(FDA) health information relative to adverse events with respect
to product defects, product recalls, repairs or replacement.
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Public
Health
FPS may disclose your health information, as required by law,
to public health or legal authorities charged with preventing
or controlling disease, injury or disability. |
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Law enforcement
FPS may disclose health information for law enforcement purposed
as required by law or in response to a valid subpoena. |
Your Health Information Rights
Although your health record is the physical
property of FPS, the information it contains belongs to you. You have
the right to:
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Request a
restriction on certain uses and disclosures of your information
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Obtain a paper
copy of the notice of information practices upon request |
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Inspect a
copy of your health record |
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Amend your
health record as provided in 45 CFR 164.528 |
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Obtain an
accounting of disclosures of your health information |
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Request communication
of your health information by alternative means or at alternative
locations. |
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Revoke your
authorization to use or disclose health information except to
the extent that action has already been taken. |
Our Responsibility
FPS is required to:
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Maintain the
privacy of your health information |
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Provide you
with a notice as to FPS' legal duties and privacy practices
with respect to information FPS collects and maintains about
you |
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Abide by the
terms of this notice |
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Notify you
if FPS is unable to agree to a requested restriction |
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Accommodate
reasonable requests you may have to communicate health information
by alternative means or at alternative locations |
FPS reserves the right to change practices and to make
the new provisions effective for all protected health information
FPS maintains. Should FPS' information practices change, we will make
a reasonable effort to notify you of this change.
For More Information or to Report a Problem
If you have questions, or it you want to report a problem, please
contact Kerry, FPS' Privacy Officer at 510-268-3720. Complaints may
also be filed with the Secretary of Health and Human Services, an
act for which no retaliation will occur.
I have read this privacy notice and I have been given ample time
to ask questions regarding the information it contains. I understand
Family Planning Specialists will hold my record to the highest standard
of privacy and confidentiality and will only release my personal health
information when so authorized by me in writing, or when required
by law to do so.
_____________________________/________________
Signature | Date
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