VALLEY LASER AND SURGERY CENTER, INC.
36 W. Yokuts Avenue, Suite 3 Stockton, CA 95207
(209)952-1189 Fax (209)952-1174
NOTICE OF PRIVACY PRACTICES
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.
This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI in some cases. Your “protected health information” means any written and oral health information about you, including demographic data that can be used to identify you. This is health information 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.
I. Uses and Disclosures of Protected Health Information (PHI)
Valley Laser and Surgery Center, Inc. may use your PHI for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your PHI may be used or disclosed only for these purposes unless the facility has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your PHI for the purposes described in this Privacy Notice may be made in writing, orally, via phone by voice message machine or by facsimile.
A. Treatment – We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes.
B. Payment – Your PHI will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the procedure that we have scheduled.
C. Operation – We may use or disclose your PHI as necessary, for our own health care operations to facilitate the function of Valley Laser and Surgery Center, Inc. and to provide quality care to all patients.
D. Other Uses and Disclosures – As part of treatment, payment and health care operations, we may also use or disclose your PHI for the following purposes: to remind you of your surgery date.
II. Uses and Disclosures beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose your PHI without your permission or authorization for a number of reasons including the following: when legally required; when there are risks to public health; to report suspected abuse, neglect or domestic violence; to conduct health oversight activities; in connection with judicial and administrative proceedings; for law enforcement purposes; to coroners, funeral directors, and for organ donation; for research purposes; in the event of a serious threat to health or safety; for specified government functions; for worker’s compensation.
III. Uses and Disclosures Permitted without Authorization but with Opportunity to Object
We may disclose your PHI to your family member to a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death. 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 PHI as described.
IV. Uses and Disclosures which you authorize
Other than as stated above, we will not disclose your PHI other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.
V. Your Rights
You have the following rights regarding your health information:
A. The right to inspect and copy your PHI – You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain the PHI. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to a law that prohibits access to PHI. Depending on the circumstances, you may have the right to have a decision to deny access reviewed. We may deny your request to inspect or copy your PHI if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety of that of another person, or that is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision. To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request. Please contact our Privacy Officer if you have questions about access to your medical record.
B. The right to request a restriction on uses and disclosures of your PHI – You may ask us not to use or disclose certain parts of your PHI for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.
C. The right to receive confidential communications from us by alternative means or at an alternative location – You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other methods of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.
D. The right to request amendments to your PHI – You may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.
E. The right to receive an accounting – You have the right to receive an accounting of certain disclosures of your PHI made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
F. The right to obtain a paper copy of this notice - Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of this notice.
VI. Our Duties
The facility is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future PHI that we maintain. If the facility changes its Notice, we will provide a copy of the revised Notice by either sending a copy of the revised Notice via regular mail or through in-person contact for those patients who visit in the future.
VII. Complaints
You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the facility’s Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
VIII. Contact Person
The facility’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to our Privacy Officer by sending it to:
Valley Laser and Surgery Center, Inc.
36 W. Yokuts Avenue, Suite 3
Stockton, CA 95207
The Privacy Officer can be contacted by telephone at (209) 952-1189.
