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Central Coast UrgentCare

Medical Group

NOTICE OF PRIVACY PRACTICES
Central Coast UrgentCare Medical Group
Privacy Officer 805-922-0561, ext. 11
Effective Date: September 23, 2013
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.


We understand the importance of privacy and are committed to maintaining the confidentiality of
your medical information. We make a record of the medical care we provide and may receive
such records from others. We use these records to provide or enable other health care
providers to provide quality medical care, to obtain payment for services provided to you as
allowed by your health plan and to enable us to meet our professional and legal obligations to
operate this medical practice properly. We are required by law to maintain the privacy of
protected health information, to provide individuals with notice of our legal duties and privacy
practices with respect to protected health information, and to notify affected individuals following
a breach of unsecured protected health information. This notice describes how we may use and
disclose your medical information. It also describes your rights and our legal obligations with
respect to your medical information. If you have any questions about this Notice, please contact
our Privacy Officer listed above.


TABLE OF CONTENTS
A. How This Medical Practice May Use or Disclose Your Health Information………………..p.2
B. When This Medical Practice May Not Use or Disclose Your Health Information…………p.5
C. Your Health Information Rights……………………………………………………………… p.5
1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper or Electronic Copy of this Notice
D. Changes to this Notice of Privacy Practices .......................................................................p.7
E. Complaints ..........................................................................................................................p.7

© 2013 by PrivaPlan™ Associates, Inc. and the California Medical Association
Patent Pending. All Rights Reserved

                                                            -2-

A. How This Medical Practice May Use or Disclose Your Health Information
The medical record is the property of this medical practice, but the information in the medical
record belongs to you. The law permits us to use or disclose your health information for the
following purposes:

1. Treatment. We use medical information about you to provide your medical care. We
disclose medical information to our employees and others who are involved in providing
the care you need. For example, we may share your medical information with other
physicians or other health care providers who will provide services that we do not provide
or we may share this information with a pharmacist who needs it to dispense a prescription
to you, or a laboratory that performs a test. We may also disclose medical information to
members of your family or others who can help you when you are sick or injured, or
following your death.

2. Payment. We use and disclose medical information about you to obtain payment for the
services we provide. For example, we give your health plan the information it requires for
payment. We may also disclose information to other health care providers to assist them
in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose medical information about you to
operate this medical practice. For example, we may use and disclose this information to
review and improve the quality of care we provide, or the competence and qualifications of
our professional staff. Or we may use and disclose this information to get your health plan
to authorize services or referrals. We may also use and disclose this information as
necessary for medical reviews, legal services and audits, including fraud and abuse
detection and compliance programs and business planning and management. We may
also share your medical information with our "business associates," such as our billing
service, that perform administrative services for us. We have a written contract with each
of these business associates that contains terms requiring them and their subcontractors
to protect the confidentiality and security of your medical information. Although federal law
does not protect health information which is disclosed to someone other than another
healthcare provider, health plan, healthcare clearinghouse or one of their business
associates, California law prohibits all recipients of healthcare information from further
disclosing it except as specifically required or permitted by law. We may also share your
information with other health care providers, health care clearinghouses or health plans
that have a relationship with you, when they request this information to help them with
their quality assessment and improvement activities, their patient-safety activities, their
population-based efforts to improve health or reduce health care costs, protocol
development, case management or care coordination activities, their review of
competence, qualifications and performance of health care professionals, their training
programs, their accreditation, certification or licensing activities, their activities related to
contracts of health insurance or health benefits, or their health care fraud and abuse
detection and compliance efforts. We may also share medical information about you with
the other health care providers, health care clearinghouses and health plans that
participate with us in "organized health care arrangements" (OHCAs) for any of the
OHCAs' health care operations. OHCAs include hospitals, physician organizations, health
plans, and other entities which collectively provide health care services. A listing of the
OHCAs we participate in is available from the Privacy Official.


4. Appointment Reminders. We may use and disclose medical information to contact and
remind you about appointments. If you are not home, we may leave this information on
your answering machine or in a message left with the person answering the phone.

5. Sign-in Sheet. We may use and disclose medical information about you by having you
sign in when you arrive at our office. We may also call out your name when we are ready
to see you.

6. Notification and Communication with Family. We may disclose your health information to
notify or assist in notifying a family member, your personal representative or another
person responsible for your care about your location, your general condition or, unless you
had instructed us otherwise, in the event of your death. In the event of a disaster, we may
disclose information to a relief organization so that they may coordinate these notification
efforts. We may also disclose information to someone who is involved with your care or
helps pay for your care. If you are able and available to agree or object, we will give you
the opportunity to object prior to making these disclosures, although we may disclose this
information in a disaster even over your objection if we believe it is necessary to respond
to the emergency circumstances. 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.

7. Marketing. Provided we do not receive any payment for making these communications,
we may contact you to encourage you to purchase or use products or services related to
your treatment, case management or care coordination, or to direct or recommend other
treatments, therapies, health care providers or settings of care that may be of interest to
you. We may similarly describe products or services provided by this practice and tell you
which health plans we participate in., We may receive financial compensation to talk with
you face-to-face, to provide you with small promotional gifts, or to cover our cost of
reminding you to take and refill your medication or otherwise communicate about a drug or
biologic that is currently prescribed for you, but only if you either: (1) have a chronic and
seriously debilitating or life-threatening condition and the communication is made to
educate or advise you about treatment options and otherwise maintain adherence to a
prescribed course of treatment, or (2) you are a current health plan enrollee and the
communication is limited to the availability of more cost-effective pharmaceuticals. If we
make these communications while you have a chronic and seriously debilitating or lifethreatening
condition, we will provide notice of the following in at least 14-point type: (1)
the fact and source of the remuneration; and (2) your right to opt-out of future remunerated
communications by calling the communicator's toll-free number. We will not otherwise use
or disclose your medical information for marketing purposes or accept any payment for
other marketing communications without your prior written authorization. The authorization
will disclose whether we receive any financial compensation for any marketing activity you
authorize, and we will stop any future marketing activity to the extent you revoke that
authorization.

8. Sale of Health Information. We will not sell your health information without your prior
written authorization. The authorization will disclose that we will receive compensation for
your health information if you authorize us to sell it, and we will stop any future sales of
your information to the extent that you revoke that authorization.

9. Required by Law. As required by law, we will use and disclose your health information, but
we will limit our use or disclosure to the relevant requirements of the law. When the law
requires us to report abuse, neglect or domestic violence, or respond to judicial or
administrative proceedings, or to law enforcement officials, we will further comply with the
requirement set forth below concerning those activities.

10. Public Health. We may, and are sometimes required by law, to disclose your health
information to public health authorities for purposes related to: preventing or controlling
disease, injury or disability; reporting child, elder or dependent adult abuse or neglect;
reporting domestic violence; reporting to the Food and Drug Administration problems with
products and reactions to medications; and reporting disease or infection exposure. When
we report suspected elder or dependent adult abuse or domestic violence, we will inform
you or your personal representative promptly unless in our best professional judgment, we
believe the notification would place you at risk of serious harm or would require informing
a personal representative we believe is responsible for the abuse or harm.

11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your
health information to health oversight agencies during the course of audits, investigations,
inspections, licensure and other proceedings, subject to the limitations imposed by federal
and California law.

12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to
disclose your health information in the course of any administrative or judicial proceeding
to the extent expressly authorized by a court or administrative order. We may also
disclose information about you in response to a subpoena, discovery request or other
lawful process if reasonable efforts have been made to notify you of the request and you
have not objected, or if your objections have been resolved by a court or administrative
order.

13. Law Enforcement. We may, and are sometimes required by law, to disclose your health
information to a law enforcement official for purposes such as identifying of locating a
suspect, fugitive, material witness or missing person, complying with a court order,
warrant, grand jury subpoena and other law enforcement purposes.

14. Coroners. We may, and are often required by law, to disclose your health information to
coroners in connection with their investigations of deaths.

15. Organ or Tissue Donation. We may disclose your health information to organizations
involved in procuring, banking or transplanting organs and tissues.

16. Public Safety. We may, and are sometimes required by law, to disclose your health
information to appropriate persons in order to prevent or lessen a serious and imminent
threat to the health or safety of a particular person or the general public.

17. Proof of Immunization. We will disclose proof of immunization to a school where the law
requires the school to have such information prior to admitting a student if you have agree
to the disclosure on behalf of yourself or your dependent.

18. Specialized Government Functions. We may disclose your health information for military
or national security purposes or to correctional institutions or law enforcement officers that
have you in their lawful custody.

19. Worker's Compensation. We may disclose your health information as necessary to
comply with worker's compensation laws. For example, to the extent your care is covered
by workers' compensation, we will make periodic reports to your employer about your
condition. We are also required by law to report cases of occupational injury or
occupational illness to the employer or workers' compensation insurer.

20. Change of Ownership. In the event that this medical practice is sold or merged with
another organization, your health information/record will become the property of the new
owner, although you will maintain the right to request that copies of your health information
be transferred to another physician or medical group.

21. Breach Notification. In the case of a breach of unsecured protected health information, we
will notify you as required by law. If you have provided us with a current email address, we
may use email to communicate information related to the breach. In some circumstances
our business associate may provide the notification. We may also provide notification by
other methods as appropriate.

22. Psychotherapy Notes. We will not use or disclose your psychotherapy notes without your
prior written authorization except for the following: (1) your treatment, (2) for training our
staff, students and other trainees, (3) to defend ourselves if you sue us or bring some
other legal proceeding, (4) if the law requires us to disclose the information to you or the
Secretary of HHS or for some other reason, (5) in response to health oversight activities
concerning your psychotherapist, (6) to avert a serious threat to health or safety, or (7) to
the coroner or medical examiner after you die. To the extent you revoke an authorization to
use or disclose your psychotherapy notes, we will stop using or disclosing these notes.

23. Research. We may disclose your health information to researchers conducting research
with respect to which your written authorization is not required as approved by an
Institutional Review Board or privacy board, in compliance with governing law.
B. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this medical practice will, consistent
with its legal obligations, not use or disclose health information which identifies you without
your written authorization. If you do authorize this medical practice to use or disclose your
health information for another purpose, you may revoke your authorization in writing at any
time.


                                                              -5-

C. Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request restrictions on
certain uses and disclosures of your health information by a written request specifying what
information you want to limit, and what limitations on our use or disclosure of that
information you wish to have imposed. If you tell us not to disclose information to your
commercial health plan concerning health care items or services for which you paid for in
full out-of-pocket, we will abide by your request, unless we must disclose the information for
treatment or legal reasons. We reserve the right to accept or reject any other request, and
will notify you of our decision.


2. Right to Request Confidential Communications. You have the right to request that you
receive your health information in a specific way or at a specific location. For example, you
may ask that we send information to a particular email account or to your work address.
We will comply with all reasonable requests submitted in writing which specify how or
where you wish to receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information,
with limited exceptions. To access your medical information, you must submit a written
request detailing what information you want access to, whether you want to inspect it or get
a copy of it, and if you want a copy, your preferred form and format. We will provide copies
in your requested form and format if it is readily producible, or we will provide you with an
alternative format you find acceptable, or if we can’t agree and we maintain the record in an
electronic format, your choice of a readable electronic or hardcopy format. We will also
send a copy to any other person you designate in writing. We will charge a reasonable fee
which covers our costs for labor, supplies, postage, and if requested and agreed to in
advance, the cost of preparing an explanation or summary, as allowed by federal and
California law. We may deny your request under limited circumstances. If we deny your
request to access your child's records or the records of an incapacitated adult you are
representing because we believe allowing access would be reasonably likely to cause
substantial harm to the patient, you will have a right to appeal our decision. If we deny your
request to access your psychotherapy notes, you will have the right to have them
transferred to another mental health professional.


4. Right to Amend or Supplement. You have a right to request that we amend your health
information that you believe is incorrect or incomplete. You must make a request to amend
in writing, and include the reasons you believe the information is inaccurate or incomplete.
We are not required to change your health information, and will provide you with information
about this medical practice's denial and how you can disagree with the denial. We may
deny your request if we do not have the information, if we did not create the information
(unless the person or entity that created the information is no longer available to make the
amendment), if you would not be permitted to inspect or copy the information at issue, or if
the information is accurate and complete as is. If we deny your request, you may submit a
written statement of your disagreement with that decision, and we may, in turn, prepare a
written rebuttal. You also have the right to request that we add to your record a statement of
up to 250 words concerning anything in the record you believe to be incomplete or
incorrect. All information related to any request to amend or supplement will be maintained
and disclosed in conjunction with any subsequent disclosure of the disputed information.

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of
disclosures of your health information made by this medical practice, except that this
medical practice does not have to account for the disclosures provided to you or pursuant
to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3
(health care operations), 6 (notification and communication with family) and 18 (specialized
government functions) of Section A of this Notice of Privacy Practices or disclosures for
purposes of research or public health which exclude direct patient identifiers, or which are
incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures
to a health oversight agency or law enforcement official to the extent this medical practice
has received notice from that agency or official that providing this accounting would be
reasonably likely to impede their activities.

6. You have a right to notice of our legal duties and privacy practices with respect to your
health information, including a right to a paper copy of this Notice of Privacy Practices, even
if you have previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to
exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of
Privacy Practices.

                                                                      -7-

D. Changes to this Notice of Privacy Practices


We reserve the right to amend our privacy practices and the terms of this Notice of Privacy
Practices at any time in the future. Until such amendment is made, we are required by law to
comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections
will apply to all protected health information that we maintain, regardless of when it was created
or received. We will keep a copy of the current notice posted in our reception area, and a copy
will be available at each appointment. We will also post the current notice on our website:
www.ccurgent.com


E. Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your
health information should be directed to our Privacy Officer listed at the top of this Notice of
Privacy Practices.
If you are not satisfied with the manner in which this office handles a complaint, you may submit
a formal complaint to:
Region IX
Office of Civil Rights
U.S. Department of Health & Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 (fax)
OCRMail@hhs.gov
The complaint form may be found at www.hhs.gov/ocr/privacy/hipaa/complaints/
hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.

© 2013 by PrivaPlan™ Associates, Inc. and the California Medical Association
Patent Pending. All Rights Reserved