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.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices (the “Notice”) describes Dr. Nancy Rahnama’s practices and those of Dr. Rahnama’s employees, staff, volunteers, and other personnel who are involved in your care at Nancy P Rahnama MD, APC (collectively, “Dr. Nancy”). Dr. Nancy will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition.
DR. NANCY’S PLEDGE REGARDING MEDICAL INFORMATION
Dr. Nancy understands that medical information about you and your health is personal. Dr. Nancy is committed to protecting medical information about you. In order to provide you with quality service and to comply with certain state and federal legal requirements, Dr. Nancy creates a record of the services she provides to you. This Notice applies to all of the records of your care generated by Dr. Nancy, and will tell you about the ways in which Dr. Nancy may use and disclose medical information about you. It also describes your rights and certain obligations Dr. Nancy has regarding the use and disclosure of medical information. Dr. Nancy is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect; and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
HOW DR. NANCY MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that Dr. Nancy may use or disclose protected medical information. For each category of uses and disclosures, Dr. Nancy will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Dr. Nancy is permitted to use and disclose information will fall within one of the categories.
For Treatment. Dr. Nancy may use medical information about you to provide you with medical treatment and to coordinate or manage your medical treatment and any related services. For example, we may disclose information about you to other providers involved in your treatment, and to family members or other individuals involved in your medical care.
For Payment. Dr. Nancy may use and disclose medical information about you so that Dr. Nancy can get paid for the treatment and services provided to you. For example, Dr. Nancy may need to give information to your health plan, Medi-Cal, or Medicare about treatment you receive so that they will pay for your care. Dr. Nancy may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.
For Health Care Operations. Dr. Nancy may use and disclose medical information about you to carry out activities that are necessary for internal health care operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, or as part of a contractual obligation. For example, Dr. Nancy may use medical information to review treatment and services provided at the practice or to evaluate the performance of staff and contractors caring for you.
To Individuals or Family Members Involved in Your Health Care. Unless you object, Dr. Nancy may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. Dr. Nancy may also tell your family, friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.
Emergencies. Dr. Nancy may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, Dr. Nancy will use her professional judgment to decide whether this disclosure is in your best interest.
As Required By Law. Dr. Nancy will disclose your health information when required to do so by federal, state or local law.
Workers’ Compensation. Dr. Nancy may release medical information about you for workers’ compensation or similar programs.
For Public Health Activities. Dr. Nancy may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders, and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
For Health Oversight Activities. Dr. Nancy may disclose medical information about you to a health oversight agency for activities authorized by law.
For Lawsuits and Disputes. Dr. Nancy may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Disclosure to Law Enforcement. If asked to do so by law enforcement and as authorized or required by law, Dr. Nancy may release your medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at Dr. Nancy’s office; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
To Coroners, Medical Examiners and Funeral Directors. Dr. Nancy may release medical information about you to a coroner, a medical examiner, or to a funeral director.
For Specialized Government Functions. Dr. Nancy may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.
Information About Inmates/Individuals in Custody. If you are an inmate or under the custody of a law enforcement official, Dr. Nancy may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
Disclosure For Threats to Health and Safety. In certain circumstances, Dr. Nancy may be required to disclose medical information to avert a serious threat to your health or safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
SPECIAL PROVISIONS RELATED TO YOUR PRIVACY
Psychotherapy Notes. Dr. Nancy will not release any Psychotherapy Notes without a specific authorization from you authorizing the release of such notes.
Marketing. Dr. Nancy will not release your medical information for marketing purposes without an authorization from you.
Sale of Medical Information. Dr. Nancy will not sell your medical information without an authorization from you.
You have the following rights regarding your medical information. In order to exercise these rights, you must contact Dr. Nancy’s office. You may be asked to submit a written request.
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.
Amendment. If you feel that medical information about you is incorrect or incomplete, you may ask Dr. Nancy to amend the information.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures that we may have made of your medical information.
Right to Request Restrictions. You have the right to request a restriction or limitation on medical information that Dr. Nancy uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that Dr. Nancy may disclose to family members or friends involved in your care.
Request Confidential Communications. You have the right to request that Dr. Nancy communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.
Receive a Copy. You have the right to obtain a copy of this notice.
CHANGES TO THIS NOTICE
Dr. Nancy reserves the right to change the terms of this Notice at any time. Dr. Nancy reserves the right to make the revised or changed notice effective for medical information Dr. Nancy already has about you, as well as any information Dr. Nancy will receive from you in the future. Dr. Nancy will post a copy of the current Notice at her office.
QUESTIONS AND COMPLAINTS
If you have any questions or believe that your privacy rights have been violated, you may contact Dr. Nancy’s HIPAA Privacy Officer in person or mail a written summary of your concern to:
Attn: HIPAA Privacy Officer
436 North Bedford Drive Suite #209
Beverly Hills, CA 90210 Phone: 310.299.7373
You will not be penalized or retaliated against for filing a complaint. You may file a written complaint with the Department of Health and Human Services at the following address:
Office of Civil Rights, DHHS 90 7th Street, Suite 4-‐100 San Francisco, CA 94103
Phone: 415.437.8310 Fax: 415.437.8329
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written authorization. If you give Dr. Nancy permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, Dr. Nancy will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if Dr. Nancy has already acted in reliance on your permission. You understand that Dr. Nancy is unable to take back any disclosure Dr. Nancy has already made with your permission and that Dr. Nancy is required to retain its records of the care that Dr. Nancy provided to you.