NOTICE OF PRIVACY PRACTICES FOR EZCARE MEDICAL CLINIC OF CALIFORNIA,
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
EzCare Medical Clinic , Inc., P.C. d/b/a EzCare Clinic
(“EzCare”) is committed to protecting your privacy
and understands the importance of safeguarding your medical
information. We are required by federal law to maintain the privacy of
health information that identifies you or that could be used to
identify you (known as “Protected Health
Information” or “PHI”). We also are
required to provide you with this Notice of Privacy Practices
(“Notice”), which explains our legal duties and
privacy practices, as well as your rights, with respect to PHI that we
collect and maintain. We are required by federal law to abide by the
terms of this Notice currently in effect. However, we reserve the right
to change the privacy practices described in this Notice and make the
new practices effective for all PHI that we maintain Should we make
such a change, you may obtain a revised Notice by calling our office
and requesting a revised copy be sent in the mail, or accessing our
website at http://www.ezcareclinic.com/.
USES AND DISCLOSURES OF
PROTECTED HEALTH INFORMATION
A. Routine Uses and Disclosures of Protected Health Information
We are permitted under federal law to use and disclose PHI, without
your written authorization, for certain routine uses and disclosures,
such as those made for treatment, payment, and the operation of our
business. The following are examples of the types of routine uses and
disclosures of PHI that we are permitted to make. While this list is
not exhaustive, it should give you an idea of the routine uses and
disclosures we are permitted to make.
For Treatment: We will use and disclose your PHI to provide,
coordinate, or manage your treatment. We may disclose medical
information about you to our physicians, to other health care providers
treating you who are not part of EzCare, and to other personnel
involved in your health care.
For Payment: Your PHI will be used, as needed, to obtain payment for
the health care services we provide you. We may use and disclose
medical information about your treatment and services to bill and
collect payment from you, your insurance company or a third party
payer. For example, we may need to give your insurance company
information before it approves or pays for the health care services we
recommend for you. The insurance company may use that information in
connection with making a determination of eligibility or coverage for
insurance benefits, reviewing services provided to you for medical
necessity, and undertaking utilization review activities.
For Health Care Operations: We may use or disclose your PHI in order to
support the business activities of this medical practice. These
activities may include, but are not limited quality assessment
activities, practice accreditation, employee review activities,
billing, and licensing, marketing, legal advice, accounting support and
conducting or arranging for other business activities. For example, we
may use or disclose your protected health information, as necessary, to
contact you by mail to remind you of your appointment by reminder cards.
California law provides that we may disclose your PHI under certain
circumstances to organized committees and agents of professional
societies or of medical staffs of licensed hospitals, licensed health
care service plans, professional standards review organizations, and
persons or organizations insuring, responsible for or defending
professional liability we may incur.
B. Uses and Disclosures That May Be Made Without Your Authorization or
Opportunity to Object We may use or disclose your PHI in the following
situations without your authorization or providing you the opportunity
Required by the Secretary of the Department of Health and Human
Services: We may be required to disclose your PHI to the Secretary of
the Department of Health and Human Services
(“Secretary”) to investigate or determine our
compliance with the requirements of the final rule on Standards for
Privacy of Individually Identifiable Health Information.
Required By Law: We may use or disclose your PHI to the extent that the
use or disclosure is otherwise required by federal, state or local law.
Public Health: We may disclose your PHI for public health activities,
such as disclosures to a public health authority or other government
agency that is permitted by law to collect or receive the information
(e.g., the Food and Drug Administration).
California law provides that we may disclose basic information,
including your name, city of residence, age, sex, and general condition
to a state or federally-recognized disaster relief organization for
purposes of responding to disaster welfare inquiries.
California law further provides that we may not disclose HIV status
without your authorization or other person authorized by law, except as
authorized by state law or required under federal law.
Health Oversight: We may disclose PHI to a health oversight agency for
activities authorized by law, such as audits, investigations, and
inspections. Oversight agencies include government agencies that
oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: If you have been a victim of abuse, neglect, or
domestic violence, we may disclose your PHI to a government agency
authorized to receive such information. In addition, we may disclose
your PHI to a public health authority that is authorized by law to
receive reports of child abuse or neglect.
California Minors: If you are a minor, California law provides that we
may disclose your PHI to a county social worker, a probation officer,
or any other person who is legally authorized to have custody or care
of a minor for the purpose of coordinating certain health care services
and medical treatment provided to the minor.
Judicial and Administrative Proceedings: We may disclose your PHI in
response to an order of a court or administrative tribunal (to the
extent such disclosure is expressly authorized), and, in certain
circumstances, in response to a subpoena, discovery request or other
California law provides that we may disclose your PHI if the disclosure
is compelled by a board, commission or administrative agency for
purposes of adjudication or pursuant to an investigative subpoena or is
compelled by an arbitrator or arbitration panel pursuant to a subpoena
duces tecum under certain circumstances.
California law further provides that we may disclose your PHI to the
extent it is relevant to your condition, care or treatment to a probate
court investigator in the course of an investigation required or
authorized in a conservatorship proceeding under California law.
Law Enforcement: We may disclose your PHI, so long as applicable legal
requirements are met, for law enforcement purposes, such as providing
information to the police about the victim of a crime.
California law provides that we may disclose your PHI to a governmental
law enforcement agency pursuant to a lawfully issued search warrant.
Coroners and Funeral Directors: We may disclose your PHI to a coroner,
medical examiner, or funeral director if it is needed to perform their
legally authorized duties.
Organ Donation: If you are an organ donor, we may disclose your PHI to
organ procurement organizations as necessary to facilitate organ
donation or transplantation.
If you are a tissue donor, California law provides that we may disclose
your PHI to a tissue bank as necessary to facilitate tissue donation or
Research: Under certain circumstances, we may disclose your PHI to
researchers when their research has been approved by an institutional
review board that has reviewed the research proposal and established
protocols to ensure the privacy of your PHI.
Serious Threat to Health or Safety: We may disclose your PHI if we
believe it is necessary to prevent a serious and imminent threat to the
public health or safety and the disclosure is made to someone we
reasonably believe is able to prevent or lessen the threat.
Specialized Government Functions: When the appropriate conditions
apply, we may disclose PHI for purposes related to military or national
security concerns, such as for the purpose of a determination by the
Department of Veterans Affairs of your eligibility for benefits.
Workers’ Compensation: We may disclose your PHI as necessary
to comply with workers’ compensation laws and other similar
Inmates: We may use or disclose your PHI if you are an inmate of a
correctional facility and we created or received your PHI in the course
of providing care to you.
Business Associates: We may disclose your PHI to persons who perform
functions, activities or services to us or on our behalf that require
the use or disclosure of PHI. To protect your health information, we
require the business associate to appropriately safeguard your
C. Uses and Disclosures That May Be Made Either With Your Agreement or
the Opportunity to Object
Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, orally or in
writing, your PHI that directly relates to that person’s
involvement in your health care. If you are unable to agree or object
to such disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional
judgment. We may use or disclose your PHI to notify or assist in
notifying a family member, personal representative or any other person
that is responsible for your care of your location or general condition.
California law provides that we may disclose such information to a
family member, other relative, domestic partner, a close personal
friend, or any other person identified by you.
D. Uses and Disclosures of Protected Health Information Based upon Your
Marketing: We must obtain your written authorization to use and
disclose your PHI for most marketing purposes.
Sale of PHI: We must obtain your written authorization for any
disclosure of your PHI which constitutes a sale of PHI.
California law provides that we may not intentionally share, sell, use
for marketing, or otherwise use your medical information for a purpose
not necessary to provide health care services to you, except to the
extent expressly authorized by you.
Other Uses: Other uses and disclosures of your PHI, not described
above, will be made only with your written authorization. You may
revoke your authorization, at any time, in writing, except to the
extent that we have taken action in reliance on the authorization.
YOUR RIGHTS REGARDING
HEALTH INFORMATION ABOUT YOU
You have certain rights regarding your PHI, which are explained below.
You may exercise these rights by submitting a request in writing to our
A. You have the right to inspect and copy your PHI. If you would like
to see or copy your PHI that is contained in a designated record set
(e.g., medical and billing records), we are required to provide you
access to such PHI for inspection and copying within 30 days after
receipt of your request (with up to a 30-day extension if needed). We
may charge you a reasonable fee to cover duplication, mailing and other
costs incurred by us in complying with your request. In addition, there
are situations where we may deny your request for access to your PHI.
For example, we may deny your request if we believe the disclosure will
endanger your life or that of another person. Depending on the
circumstances of the denial, you may have a right to have this decision
Under California law, we must permit you or your representative to
inspect your medical records during business hours within five (5)
working days after receipt of a written request by you or your
California law further provides that you or your representative are
entitled to copies of all or any portion of your patient records upon
presenting a written request specifying the records to be copied,
together with a fee to defray the cost of copying, that shall not
exceed twenty-five cents ($0.25) per page or fifty cents ($0.50) per
page for records that are copied from microfilm and any additional
reasonable clerical costs incurred in making the records available. We
are required to ensure that the copies are transmitted within fifteen
(15) days after receiving the written request. We may choose to prepare
a summary of your medical record rather than allowing access to the
entire record, in which case we must make the summary of the record
available to you within ten (10) working days (with up to a 20-day
extension if needed) from the request date.
B. You have the right to request a restriction of your PHI. This means
you may ask us not to use or disclose any part of your PHI for purposes
of treatment, payment or health care operations. You may also request
that any part of your PHI not be disclosed to family members or friends
who may be involved in your care or for notification purposes as
described in this Notice. Your request must state the specific
restriction requested and to whom you want the restriction to apply. We
are not required to agree to a restriction that you may request, except
we must agree not to disclose your PHI to your health plan if the
disclosure (1) is for payment or health care operations and is not
otherwise required by law, and (2) relates to a health care item or
service which you paid for in full out of pocket. If we agree to the
requested restriction, we may not use or disclose your PHI in violation
of that restriction unless it is needed to provide emergency treatment.
C. You have the right to request to receive confidential communications
from us by alternative means or at an alternative location. We will
accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will be
handled or specification of an alternative address or other method of
D. You have the right to amend your PHI. This means you may request an
amendment of your PHI in our records that is contained in a designated
record set (e.g., medical and billing records) for as long as we
maintain the PHI. We will respond to your request within 60 days (with
up to a 30-day extension if needed). We may deny your request if, for
example, we determine that your PHI is accurate and complete. If we
deny your request, we will send you a written explanation and allow you
to submit a written statement of disagreement.
E. You have the right to receive an accounting of certain disclosures
that we have made of your PHI. You have the right to receive an
accounting of certain disclosures we have made, if any, of your PHI.
This right only applies to disclosures for purposes other than
treatment, payment or health care operations as described in this
Notice. It also excludes disclosures we may have made to you, your
family members or friends involved in your care. The right to receive
this information is subject to certain exceptions, restrictions and
limitations. You must specify a time period for the accounting, which
may not be longer than 6 years and cannot include any date before April
14, 2003. You may request a shorter timeframe. You have the right to
one free request within any 12-month period, but we may charge you for
any additional requests in the same 12-month period. We will notify you
about any such charges, and you are free to withdraw or modify your
request in writing before any charges are incurred. We will respond to
your request within 60 days (with up to a 30-day extension if needed).
F. You have the right to obtain a paper copy of this Notice from us.
You have the right to receive a paper copy of this Notice upon request.
You may ask us to give you a copy of this Notice at any time.
G. You have the right to be notified if you are affected by a breach of
H. You have the right to opt out of receiving fundraising
communications from us. We may contact you for fundraising purposes.
You have the right to opt out of receiving these communications.
If you believe that we have violated your privacy rights, you may file
a complaint with us by notifying our Privacy Officer in writing at the
EzCare Medical Clinic, Inc.
1884 Market St
San Francisco, California 94102