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October 16, 2005
NOTICE OF PRIVACY PRACTICES
To Our Patients: This notice
describes how health information about you (as a patient of this
practice) may be used and disclosed, and how you can get access to your
health information. This is required by the Privacy Regulations created
as a result of the Health Information Portability and Accountability Act
of 1996 (HIPAA).
OUR COMMITTMENT TO YOUR PRIVACY:
* Our practice is dedicated to maintaining the privacy of your health
information. We are required by law to maintain the confidentiality of
your health information.
* We realize that these laws are complicated, but we
must provide you with the following important information.
USE AND DISCLOSURE OF YOUR HEALTH
INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES:
The following circumstances may require us to use or disclose your
health information:
1. To public health authorities and health oversight agencies that are
authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or
administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health
and safety or the health and safety of another individual or the public.
We will only make disclosures to a person or organization able to help
prevent the threat.
5. If you are a member of U.S. or foreign military forces (including
veterans) and if required by the appropriate authorities.
6. To federal officials for intelligence and national security
activities authorized by law.
7. To correctional institutions or law enforcement officials if you are
an inmate or under the custody of a law enforcement official.
8. For Workers Compensation and similar programs.
YOUR RIGHTS REGARDING YOUR HEALTH
INFORMATION:
1. Communications. You can request that our practice communicate with
you about your health and related issues in a particular manner or at a
certain location. For instance, you may ask that we contact you at home,
rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health
information for treatment, payment, or health care operations.
Additionally, you have the right to request that we restrict our
disclosure of your health information to only certain individuals
involved in your care or the payment for your care, such as family
members and friends. We are not required to agree to your request;
however, if we do agree, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information is
necessary to treat you.
3. You have the right to inspect and obtain a copy of the health
information that my be used to make decisions about you, including
patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to: XPert
Fertility Care of California/Minh N. Ho, M.D., 5555 Reservoir Dr., Suite #205,
San Diego, CA 92120.
4. You may ask to amend your health information if you believe it is
incomplete, and as long as the information is kept by or for our
practice. To request an amendment, your request must be made in writing
and submitted to: XPert Fertility Care of California/Minh N. Ho, M.D.,
5555 Reservoir Dr., Suite #205, San Diego, CA 92120. You must provide us with a reason
that supports your request for amendment.
5. Right to a copy of this notice: You are entitled to receive a copy of
the Notice of Privacy Practices. You may ask us to give you a copy of
the Notice at any time. To obtain a copy of this notice, contact our
front desk receptionist.
6. Right to file a complaint: If you believe your privacy rights have
been violated, you may file a complaint with our practice or with the
secretary of the Department of Health and Human Services. To file a
complaint with our practice, contact Dung Thai, Privacy Officer, for
XPert Fertility Care of California/Minh N. Ho, M.D., 5555 Reservoir Dr., Suite #205,
San Diego, CA 92120. all complaints must be submitted in writing. You
will not be penalized for filing a complaint.
7. Right to provide an authorization for other uses and disclosures: Our
practice will obtain your written authorization for uses and disclosures
that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our
health information privacy policies, please contact Dung Thai at
(619) 286-5858.
I hereby acknowledge that I have been
presented with a copy of XPert Fertility Care of California/Minh
N. Ho, M.D., . Notice of
Privacy Practices.
Signature:
____________________________________________
Date:
________________________________________________
Name of Patient:
_______________________________________
Employee Initials:
_________________________
Xpert Fertility Care of
California / Minh N. Ho, M.D., F.A.C.O.G.
5555 Reservoir Drive, Suite 205 San Diego, CA 92120
Tel: (619) 286-5858 Fax: (619) 286-1474
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