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 Insurance Provability and Accountability Act of 1996 (HIPAA). We realize that these laws are lengthy and complicated, but we must provide the following information.
OUR COMMITMENT TO YOUR PRIVACY
Our practice is required by law and is dedicated to maintain your health information in the strictest confidence. Rest assure that we spare no expense in securing your privacy. There may be a number of circumstances in which it is imperative to share your medical information.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION
Executive Medicine, Inc. may disclose your health information to other providers or medical facilities for the purpose of payment, health care operations such as imaging, laboratory and other testing procedures, and treatment. We may also share medical information with your billing institutions for the purpose of collecting payment for services rendered. Our office may also have one or more persons other than your treating physician privy to your medical information for the purpose of administrative and other business operations.
USE AND DISCLOSURE OF YOUR HEALTH INFORMATION: 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 the information is required by the appropriate authorities.
6. To federal officials for intelligence and national security purposes required by
7. To correctional institutions or law enforcement officials, e.g if you are an inmate or under the custody of a law enforcement official.
8. For the purpose of worker’s compensation case settlements or disability assessments.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
1. Communications. You can request that our practice communicate with you regarding your health and related medical information in a manner of your choosing. For instance, you may request that we contact you at home, at your hotel or at work, via e-
2. You can request a restriction or allowance in the use or disclosure of your health information to designated persons of your choosing. For instance, you have the right to request that we restrict or disclose your health information to only certain individuals involved in your care or in the payment for your care. This might include family members and friends. We do our best to accommodate our patients, 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 may be used to make decisions about you, including patient medical records and billing records. Psychotherapy notes may not be included in the above referenced information. You may submit a request in writing with your signature to obtain a copy of your medical records. Address your request to: MIMPC PO Box 2063 •Monrovia, CA 91017 or fax it to (877) 254-
4. You may ask us to amend your health information if you believe it is incorrect or incomplete. Submit your request in writing to: MIMPC PO Box 2063 •Monrovia, CA 91017. We also ask that you provide us with a reason that supports your request for amendment.
5. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, print a copy from here or call our office at (877)254-
6. If you believe your privacy rights have been violated, you may file a complaint with our office. All complaints must be submitted in writing to: MIMPC ATTN: Dr. Ulin Sargeant, PO Box 2063 •Monrovia, CA 91017. You will in no way be penalized for filing a complaint.
7. You have the right to provide an authorization for other uses and disclosures of your health information that is not otherwise explained by this notice or permitted by applicable law.