Pacific Psychiatry, Inc. (“PAC Inc.”) will ask you to sign an Acknowledgment Notice of Privacy Issues (“Acknowledgement Notice”) that you have received this Notice of Privacy Practices (“Notice”). This Notice describes, in accordance with the HIPAA Privacy Regulation, how PAC Inc. may use and disclose your protected health information to carry out treatment, payment or health care operations, and for other specific purposes that are permitted or required by law. The Notice also describes your rights and PAC Inc.’s duties with respect to protected health information about you.
PAC Inc. will store information provided by you in a computer system. That information will include your name, address, phone number and other identifying information. In addition, any information that you provide concerning medications that you are taking, medical conditions you may have, allergies, and other matters affecting your health may be stored in the computer.
We will use your health care information to treat you. For example, we will use health care information to administer psychiatric and medical treatment and to prescribe medications. We may also disclose your information to other health care providers for the purpose of treatment, however, this will occur only after we have requested your permission and have obtained your written Consent on the Consent for Release of Psychiatric, School or Medical Information or Records (“Release of Information”) Form.
We may use your health care information to receive payment for psychiatric and medical services. For examples, we may contact your third party payor (for example, insurer or insurance benefits manager) to determine whether your program will pay for your treatment. We will bill you and/or a third party payor for the cost of the psychiatric and medical treatment services provided for you. The information on or accompanying the bill may include your identification, a psychiatric or medical diagnosis, as well as the CPT Codes for treatment which has been provided. We will use your health care information to carry out health care operations. For example, we may use information in your health care record to monitor the quality of medical and psychiatric care and to train PAC Inc. personnel.
Using our judgment as health care professionals, PAC Inc. physicians and staff may disclose limited health information to whomever you designate after we have obtained your Consent and you have signed the Release of Information Form. This may include other health care providers and consultants, a family member, other relative, close personal friend, or any person for whom you have Consented and signed a Release of Information Form.
We form contracts with some entities known as Business Associates to perform services for us. For example, we sometimes require Business Associates to process insurance or other third party payor claims for submission to the actual payor. We may disclose protected health information to our Business Associates so that they can perform the medical billing job we asked them to do.
We require the Business Associates to appropriately safeguard the protected health information. We may contact you to provide appointment reminders or information about treatment or other health related benefits and services that may be of interest.
We may disclose your health care information to the following entities under given circumstances:
California law limits disclosure of your medical information in ways that would otherwise be permitted under federal law. In the situations described below, PAC Inc. may disclose your medical information as follows: (a) the information may be disclosed to providers of health care, health care service plans, contractors or other health care professionals or facilities for purposes of diagnosis or treatment of the patient. This includes, in an emergency situation, the communication of patient information by radio transmission or other means between licensed emergency medical personnel at the scene of an emergency, or in an emergency medical transport vehicle, and licensed emergency medical personnel at a health facility; (b) the information may be disclosed to an insurer, employer, health care service plan, hospital service plan, employee benefit plan, governmental authority, contractor or any other person or entity responsible for paying for health care services rendered to the patient to the extent necessary to allow responsibility for payment to be determined and payment to be made. If the patient is, by reason of a comatose or other disabling medical condition, unable to consent to the disclosure of medical information and no other arrangements have been made to pay for the health care services being rendered to the patient, the information may also be disclosed to a government authority to the extent necessary to determine the patient’s eligibility for, and to obtain, payment under governmental program for health care services provided to the patient. The information may also be disclosed to another provider of health care or health care service plan as necessary to assist the other provider or health care service plan in obtaining payment for health care services rendered by that provider of health care or health care service plan to the patient; (c) the information may be disclosed to any person or entity that provides billing, claims management, medical data processing, or other administrative services for providers of health care or health care service plans or for any of the persons or entities specified above in paragraph (b). However, no information so disclosed may be further disclosed by the recipient in any way that would be violative of California laws governing the use and disclosure of medical information with our authorization from the patient; (d) the information may be disclosed to organized committees and agents of professional societies or of medical staffs of licensed hospitals, licensed health care service plans, professional standards review organizations, independent medical review organizations and their selected reviewers, utilization and quality control peer review organizations, contractors or persons or organizations insuring, responsible for, or defending professional liability that a provider may incur, if the committees, agents, health care service plans, organizations, reviewers, contractors or persons are engaged in reviewing the competence or qualifications of health care professionals or in reviewing health care services with respect to medical necessity, level of care, quality of care, or justification of charges; (e) a provider of health care or health care service plan that has created medical information as a result of employment-related health care services to an employee conducted at the specific prior written request and expense of the employer may disclose to the employee’s employer that: (1) is relevant in a law suit, arbitration, grievance, or other claim or challenge to which the employer and the employee are parties and in which the patient has placed in issue his or her medical history, mental or physical condition, or treatment, provided that information may only be used or disclosed in connection with that proceeding; (2) describes functional limitations of the patient that may entitle the patient to leave from work for medical reasons or limit the patient’s fitness to perform his or her present employment, provided that no statement of medical cause is included in the information disclosed; (f) unless the provider of health care or health care service plan is notified in writing of an agreement by the sponsor, insurer, or administrator to the contrary, the information may be disclosed to a sponsor, insurer, or administrator of a group or individual insured or uninsured plan or policy that the patient seeks coverage by or benefits from, if the information was created by the benefits from, if the information was created by the provider of health care or health care service plan as the result of service conducted at the specific prior written request and expense of the sponsor, insurer, or administrator for the purpose of evaluating the application for coverage or benefits; (g) the information may be disclosed to a health care service plan by providers of health care that contract with the health care service plan and may be transferred among providers of health care that contract with the health care service plan. Medical information may not otherwise be disclosed by a health care serve plan except in accordance with the provisions of this part; (h) the information may be disclosed to an insurance institution, agent or support organizations of medical information if the insurance institution, agent, or support organization has complied with all requirements for obtaining the information pursuant to the requirements of the California Insurance Code provisions; (i) the information may be disclosed to an organ procurement organization or tissue bank processing the tissue of a decedent for transplantation into the body of another person, but only with respect to the donating decedent for the purpose of aiding the transplant; (j) the information may be disclosed to a third party for purposes of encoding, encrypting, or otherwise anonymizing data. However, no information may be further disclosed by the recipient in any way that would be unauthorized manipulation of coded or encrypted medical information that reveals individually identifiable medical information; (k) for purposes of disease management programs and services, information may be disclosed to any entity contracting with a health care service plan or the health care service plan’s contractors to monitor or administer care of enrollees for covered benefit, provided that the disease management services and care are authorized by a treating physician or to any disease management organization that complies fully with the physician authorization requirements, provided that the health care service plan or its contractor provides or has provided a description of the disease management services to a treating physician or to the health care service plan’s or contractor’s network of physicians.
We will obtain your written Consent on a signed Release of Information Form before using or disclosing protected health information about you for purposes other than those listed above or otherwise permitted or required by law. You may revoke an authorization in writing at any time. Such revocations must be made in writing. Making revocation should be sent to 175 Santa Rosa Street, San Luis Obispo, CA 93405. Upon receipt of the written revocation, we will stop using or disclosing protected health information about you, except to the extent that we have already taken action in reliance on the Authorization.
You have the right to request that we restrict how your protected health information is used or disclosed in carrying out treatment, payment, or health care operations. Such requests must be made in writing to 175 Santa Rosa Street, San Luis Obispo, CA 93405. We are not required to agree to the requested restrictions, that agreement will be binding on us.
You have the right to request that our communications to you concerning your health care information be made by alternative means or at alternative locations. For example, you may wish us to communicate in some way other than mailing to your home address or calling your home telephone number. Such requests should be made in writing to 175 Santa Rosa Street, San Luis Obispo, CA 93405. We will comply with a reasonable request for such an alternative.
You have the right to inspect and obtain a copy of your protected health information in accordance with the standard of care for Psychiatric and Medical Practice in this geographic area. You have the right to access a copy protected information about you contained in the designated record set for as long as we maintain your protected health information. The designated record set usually may include psychiatric and medical initial assessment and treatment recommendations, diagnostic and treatment information, psychological and educational testing reports, diagnostic medical laboratory and other testing reports, other medical and psychiatric records obtained from other mental health and medical practitioners involved with the your care, mental health and medical practitioners consulted during the course of your treatment, other parties acquired during and for the purpose of psychiatric and medical treatment, record of communication with third parties acquired during the administration of and for the purpose of psychiatric and medical treatment, medication and billing records. To receive a copy of your protected health information, you must send a written request to PAC Inc. at 175 Santa Rosa Street, San Luis Obispo, CA 93405. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request. We may also deny your request to inspect and copy limited circumstances. If you are denied access to your protected health information in most cases you may request that the denial be reviewed.
If you feel that the protected health information we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an Amendment for as long as we maintain the protected health information. A request for and Amendment must be made in writing. Such requests should be sent to PAC Inc. at 175 Santa Rosa Street, San Luis Obispo, CA 93405. You must include a reason that supports your request. If the request for Amendment is denied, you have the right to file a statement of disagreement with the decisions, and we may give a rebuttal to your statement. ACCOUNTING For most purposes other than treatment, payment, or health care operations, you have the right to receive an Accounting of the disclosures we made, on or after April 14, 2003, of your protected health information. The Accounting will exclude disclosures to persons involved in your care, and disclosures for purposes you specifically authorized in writing. Your request should be sent to 175 Santa Rosa Street, San Luis Obispo, CA 93405. The time period for the requested accounting must be specified and it may not be longer than six years. The first Accounting you request within a 12-month period will be provided free of charge, but you may be charged for the cost of providing additional Accountings within that period. We will notify you of the cost involved and you may choose to withdraw or modify the request at that time.
You have a right to receive a paper copy of this Notice from us upon request even if you have already received the Notice electronically (for example, on the internet).
PAC Inc. takes responsibility for maintaining your protected health information in confidence very seriously. Protected health information means information about you that may identify you and that related to your past, present or future mental or physical health or condition and related health care services. It also includes basic demographic information. We are required by law to maintain the privacy of protected health information and to provide you with a Notice of Privacy Practices including our legal duties with respect to protected health information. In addition, PAC Inc. is required to abide by the terms of the Notice that is currently in effect.
If you have any questions or would like additional information about our privacy practices, you may contact the office PAC Inc., (805) 541-6000 or by writing to 175 Santa Rosa St., San Luis Obispo, CA. 93405. There will be no retaliation for filing a complaint.