This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

Effective Date: April 14, 2003

This medical practice attains health information about you and stores it in a chart and a computer to maintain your medical record. While the information in medical records belongs to you, the medical record itself is the property of this medical practice. We are committed to preserving the privacy and confidentiality of your health information, which is created and/or maintained at our medical office. State and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your health information. This includes any information that we receive from other healthcare providers or facilities. The Notice describes the way in which we may use or disclose your health information and your rights and our obligations concerning such uses or disclosures.

• Our obligations
• Maintain the privacy of protected health information.
• Provide you with the Notice of our legal duties and privacy practices with respect to your health information.
• Abide by the terms of this Notice.
• Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed.

Changes To This Notice- We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility.

How We May Use And Disclose Health Information About You

Treatment- We may use health information about you to coordinate your medical treatment and services. We may disclose health information about you to doctors, nurses, technicians, medical students, interns, or other allied health personnel who are involved in taking care of you during your visit with us. We may also communicate information to another non-WPMC healthcare provider for the purposes of coordinating your continued care.

Payment – We may use and disclose your information for billing, and to arrange for payment from you, an insurance company, a third party, or a collection agency. This may also include the disclosure of health information to obtain prior authorization for treatment and procedures from your insurance plan.

Health Care Operations – Uses and disclosures of health information are necessary to operate our healthcare facility and to make sure all of our patients receive quality care. We may use and disclose relevant health information about you for healthcare operations. Examples include quality assurance activities, post-discharge telephone calls to follow up on your health status, granting medical staff credentials, administrative activities including WPMC Health financial and business planning and development, customer service activities including investigation of complaints, and certain marketing activities such as health education options for treatment and services.

Appointment Reminders – We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at our healthcare facility. These appointment reminders may be initiated by an automated voice message system.

Individuals Involved in Your Care or Payment for Your Care – We may disclose health information about you to a friend or family member who is involved in your medical care or payment for your care, or providing translation, such as your family or a friend you bring with you. We may make such disclosures when:

(a) we have your verbal agreement to do so;

(b) we make such disclosures and you do not object; or

(c) we can infer from the circumstances that you would not object to such disclosures, for example, if that person comes into the exam room with you. We may also notify your family about your location or general condition or disclose such information in an emergency, to an entity assisting in a disaster relief effort. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

Marketing

We may contact you to give you information about products or services related to your treatment, case management, or care coordination, or to direct or recommend other treatment or health-related benefits and services that may be of interest to you, or provide you with promotional items.

Special situations that do not require your information consent or authorization.

The following disclosures of your health information are permitted by law without any oral or written permission from you:

Organ and Tissue Donation- If you are an organ donor, we may release health information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans – If you are a member of the armed forces, we may release health information about you as required by military command authorities.

Worker’s Compensation – We may release health information about you for worker’s compensation or similar programs if you have a work-related injury. These programs provide benefits for work-related injuries.

Averting a Serious Threat to Health or Safety – We may use and disclose health information about you when necessary to prevent a serious threat to your health or safety or the health and safety of another person or the public. These disclosures would be made only to someone able to help prevent the threat.

Public Health Activities – We may disclose health information about you for public health activities. These generally include the following:

• To prevent or control disease, injury, or disability.
• To report births and deaths.
• To report child abuse or neglect.
• To report reactions to medications, problems with products, or other adverse events.
• To notify people of recalls of products they may be using.
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• To notify the appropriate government authority if we believe a patient has been the victim of abuse (including elder abuse), neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities- We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government and other authorized bodies to monitor the health care system, government programs, and compliance with civil rights laws.

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or the law enforcement official. This is necessary for the correctional institution to provide you with health care, to protect your health and safety and the health and safety of others, or for the safety and security of the correctional institution.

Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may disclose health information about you in response to a subpoena, discovery request, or other lawful processes by someone else involved in the dispute.

Law Enforcement – We may disclose health information if asked to do so by law enforcement officials for the following reasons:

• In response to a court order, subpoena, warrant, summons, or similar process.
• To identify or locate a suspect, fugitive, material witness, or missing person.
• About the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement.
• About a death we believe may be the result of criminal conduct.
• About criminal conduct at our facility.
• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Research That Does Not Involve Your Treatment- When a research study does not involve any treatment, we may disclose your health information to researchers when an Investigational Research Committee has reviewed the research protocol and has established appropriate protocols to ensure the privacy of your health information and has waived the need for authorization.

Coroners, Medical Examiners, and Funeral Home Directors – We may disclose health information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death of a person. We may also release health information about patients at our facility to funeral home directors as necessary to carry out their duties.

National Security and Intelligence Activities – We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Legal Requirements – We will disclose health information about you without your permission when required to do so by federal, state, or local law.

Situations Requiring Your Written Authorization

If there are reasons we need to use your information that have not been described in the sections above, we will obtain your written permission (called an “authorization.”) If you authorize us to use or disclose health information about you, we may continue to do so until you revoke your authorization or the authorization expires. You may revoke your authorization at any time, in writing. Please understand that we are unable to take back any disclosures or uses we have already made with your permission, and we are required to retain our records of the care that we provided to you. Some typical disclosures that would require your specific authorization are:

Special Categories of Treatment Information: In most cases, federal or state law requires your written authorization or the written authorization of your legal representative for disclosures of drug and alcohol abuse treatment, Human Immunodeficiency Virus (HIV), and Acquired Immune Deficiency Syndrome (AIDS) test results, and mental health treatment.

Research Involving Your Treatment

When a research study involves your treatment, we may disclose your health information to researchers only after you have signed a specific written authorization. In addition, an Institutional Review Committee (IRC) will already have reviewed the research proposal, established appropriate protocols to ensure the privacy of your health information, and approved the research. You do not have to sign the authorization, but if you refuse you cannot be part of the research study and may be denied research-related treatment.

Your Medical Information Rights

Although your health record is the physical property of the WPMC Health entity that created it, the information belongs to you.

You Have The Right To

Obtain a copy of this Notice of Privacy Practices upon request.

Request a restriction on certain uses and disclosures of your information. This request must be in writing. If we agree to your request, we will comply with your request unless the information is needed to provide you with emergency treatment. However, if our system capabilities do not allow us to comply with your request, we are not required to.

Inspect and request a copy of your health record. This request for inspection or copies must be in writing and directed to the WPMC. A reasonable fee for copies will be charged. We may deny your request under very limited circumstances. If you are denied access to health information, you may request that the denial is reviewed by another healthcare professional chosen by someone on our healthcare team. We will abide by the outcome of that review.

Request an amendment to your health record if you feel the information is incorrect or incomplete. Your request must be made in writing and it must include a reason that supports the request. We may deny your request if the information was not created by our health care team if it is not part of the information kept by our facility, if it is not part of the information which you are permitted to inspect and copy, or if the information is accurate and complete as stated. Please note that even if we accept your request, we are not required to delete any information from your health record.

Obtain an accounting of disclosures of your health information. An accounting will only provide information about disclosures made for purposes other than; treatment, payment, or health care operations, disclosures excluded by law, or those you have authorized.

Request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you at work, or by mail. We will accommodate requests that are reasonable for our workflow and system capabilities. Your request must be in writing and specify the exact changes you are requesting.

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Questions or Complains

If you have any questions regarding this Notice please ask the receptionist for the Manager. If you believe your privacy rights have been violated, you may file a complaint with our manager. If a favorable resolution has not been reached you may contact our Medical Director at:

Atul Bembi D.O.

7798 Cherry Ave.

Fontana, CA 92336

(909) 355-1296

If not resolved

Secretary of the Department of Health and Human Services

Office of Civil Rights, Hubert H. Humphrey Bldg.

200 Indolence Ave. S. W. Room 509F HHH Building

Washington, DC 20201