Patient Forms

HIPAA Notice of Privacy Practices

This Notice of Privacy Practices (“Notice”) describes how medical information about you may be used and disclosed and how you can get access to this information. It also describes your rights under federal law (HIPAA) and additional protections under California law.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communications (for example, contacting you at a specific phone number or address)

• Ask us to limit the information we share (we may not always be able to agree)

• Get a list (accounting) of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you (such as a medical power of attorney)

• File a complaint if you believe your privacy rights have been violated

Additional California Rights

Under California law, you may have additional rights, including:

• The right to access certain information in a more timely manner

• Additional protections for sensitive information, including mental health, HIV status, and substance use treatment records

• The right to request restrictions on disclosures of medical information to health plans if you pay out-of-pocket in full for a service

Your Choices

You have choices in how we use and share information in the following situations:

• Sharing information with family, friends, or others involved in your care

• Disaster relief situations

• Marketing communications (we will obtain your written authorization where required)

• Fundraising communications (you may opt out)

We will not share your information for purposes not described in this Notice without your written permission.

Our Uses and Disclosures

We typically use or share your health information in the following ways:

Treatment

We use your health information to provide, coordinate, or manage your nutrition care and related services. For example, we may share information with your physician or other healthcare providers involved in your care.

Healthcare Operations

We use and share your information to operate our clinic, improve services, conduct quality assessments, and contact you when necessary.

Payment

We use and share your information to bill and receive payment from health plans, insurance companies, or other third parties.

Additional Uses and Disclosures

We may share your information for the following purposes, as permitted or required by law:

• Public health and safety activities

• Health oversight activities

• Research (subject to legal requirements)

• Compliance with laws and regulations

• Organ and tissue donation requests

• Medical examiner or funeral director duties

• Workers’ compensation claims

• Law enforcement or legal proceedings

• California law (including the Confidentiality of Medical Information Act – CMIA) provides additional protections for your medical information.

• We will not disclose your medical information without your authorization except as permitted or required by law.

• Certain categories of information (such as mental health records, HIV/AIDS status, and substance use treatment records) receive heightened protection.

• We will obtain your explicit authorization before sharing information for marketing purposes where required.

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your protected health information

• Notify you promptly if a breach occurs that may have compromised your information

• Follow the duties and privacy practices described in this Notice

• Provide you with a copy of this Notice

• Not use or share your information other than as described unless you provide written authorization

Changes to This Notice

We reserve the right to change this Notice. Changes will apply to all information we maintain. The updated Notice will be posted on our website and available upon request.

Complaints

If you believe your privacy rights have been violated, you may contact us using the information below. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights or the California Department of Public Health. We will not retaliate against you for filing a complaint.