DESERT HOUSE CALL PHYSICIANS
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
Uses and Disclosures
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We are required to abide by the privacy policies and practices that are outlined in this notice. We have detailed policies and procedures that we follow to further assure the privacy rule is followed.
RIGHT TO REVISE PRIVACY PRACTICESAs permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulation. Whatever the reason for these revisions, we will provide you with a revised notice in your next visit by posting the changes in the waiting area. The revised policies and practices will be applied to all protected health information that we maintain.
REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
OFFICE MANAGER
DESERT HOUSE CALL PHYSICIANS
78-100 MAIN STREET
SUITE 207
LA QUINTA, CA 92253
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
CONTACT PERSON
The name and address of the person you can contact for further information concerning our privacy practices is:
OFFICE MANAGER
DESERT HOUSE CALL PHYSICIANS
78-100 MAIN STREET
SUITE 207
LA QUINTA, CA 92253
EFFECTIVE DATE:
The notice is effective on or after October, 2006.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Desert House Call Physicians, Inc. reserves the right to modify the privacy practices outlined in the notice.
Signature:
I have received a copy of the Privacy Practices for Desert House Call Physicians, Inc.
____________________________________________________________________________________
Name of Patient (print or type)
____________________________________________________________________________________
Signature of Patient
____________________________________________________________________________________
Date
____________________________________________________________________________________
Signature of Patient Representative
(Required if the patient is a minor or an adult who is unable to sign this form)
____________________________________________________________________________________
Relationship of Patient Representative to patient
Thank you,
Desert House Call Physicians
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
Uses and Disclosures
- Treatment: Your health information may be used by staff members or disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
- Payment: Your health information my be used to seek payment from you health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may used to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
- Health care operations: Your health information may be used as necessary to support the day-to-day activities and management of Desert House Call Physicians. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
- Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
- Public health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to Nevada’s public health department.
- Other uses and disclosures require your authorization: Disclosures of your health information or its used for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure that occurred before you notified us of your decision.
- Appointment Reminders: your health information will be used by our staff to make appointment reminders.
- Information about treatments: Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.
You have certain rights under the federal privacy standards. These include:
- The right to request restrictions on the use and disclosure of your protected health information
- The right to receive confidential communications concerning your medical condition and treatment
- The right to inspect and copy your protected health information
- The to amend or submit corrections to your protected health information
- The right to receive an accounting of how and to whom your protected health information has been disclosed
- The right to receive a printed copy of this notice.
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We are required to abide by the privacy policies and practices that are outlined in this notice. We have detailed policies and procedures that we follow to further assure the privacy rule is followed.
RIGHT TO REVISE PRIVACY PRACTICESAs permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulation. Whatever the reason for these revisions, we will provide you with a revised notice in your next visit by posting the changes in the waiting area. The revised policies and practices will be applied to all protected health information that we maintain.
REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
OFFICE MANAGER
DESERT HOUSE CALL PHYSICIANS
78-100 MAIN STREET
SUITE 207
LA QUINTA, CA 92253
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
CONTACT PERSON
The name and address of the person you can contact for further information concerning our privacy practices is:
OFFICE MANAGER
DESERT HOUSE CALL PHYSICIANS
78-100 MAIN STREET
SUITE 207
LA QUINTA, CA 92253
EFFECTIVE DATE:
The notice is effective on or after October, 2006.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Desert House Call Physicians, Inc. reserves the right to modify the privacy practices outlined in the notice.
Signature:
I have received a copy of the Privacy Practices for Desert House Call Physicians, Inc.
____________________________________________________________________________________
Name of Patient (print or type)
____________________________________________________________________________________
Signature of Patient
____________________________________________________________________________________
Date
____________________________________________________________________________________
Signature of Patient Representative
(Required if the patient is a minor or an adult who is unable to sign this form)
____________________________________________________________________________________
Relationship of Patient Representative to patient
Thank you,
Desert House Call Physicians