Name or Title of Privacy Officer: HIPAA Privacy Officer
Telephone Number: (310) 659-8640
Effective Date: December 1, 2018
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.
WHO WILL FOLLOW THIS NOTICE
This Notice of Privacy Practices (the “Notice”) describes the practices of Adam Cotsen, M.D. (“Dr. Cotsen”) and those of Dr. Cotsen’s employees, staff, volunteers, and other personnel who are involved in your care. Dr. Cotsen and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services.
DR. COTSEN’S PLEDGE REGARDING MEDICAL INFORMATION
Dr. Cotsen understands that medical information about you and your health is personal. Dr. Cotsen is committed to protecting medical information about you. In order to provide you with quality care and to comply with certain state and federal legal requirements, Dr. Cotsen creates a record of the services you receive at Dr. Cotsen’s medical practice. This Notice applies to all of the records of your care generated by Dr. Cotsen’s medical practice. This Notice will tell you about the ways in which Dr. Cotsen may use and disclose medical information about you. It also describes your rights and certain obligations Dr. Cotsen has regarding the use and disclosure of medical information. Dr. Cotsen is required by law to: (1) make sure that medical information that identifies you is kept private; (2) give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) follow the terms of the Notice that are currently in effect, and (4) notify you in case there is an unauthorized use or disclosure of your unsecured medical information.
A WORD ABOUT FEDERAL AND STATE LAW
Federal and state laws both have rules and regulations regarding the protection of your health information. California has long enforced patient privacy protections, primarily through the Confidentiality of Medical Information Act (Cal. Civil Code Section 56 et seq.) (“CMIA”) When California law and federal law differ, federal law requires that providers comply with the federal or state law that provides patients with greater protection.
HOW DR. COTSEN MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that Dr. Cotsen may use or disclose protected medical information. For each category of uses and disclosures, Dr. Cotsen will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Dr. Cotsen is permitted to use and disclose information will fall within one of the categories. Some information such as psychotherapy notes, certain drug and alcohol information, HIV, or mental health information is entitled to special restrictions.
For Treatment. Dr. Cotsen may use medical information about you to provide you with medical treatment and to coordinate or manage your medical treatment and any related services. Dr. Cotsen may disclose information about you to Dr. Cotsen’s staff or other providers involved in your treatment. Dr. Cotsen may also disclose your medical information to family members or other individuals involved in your continuing medical care after you cease receiving services from Dr. Cotsen. For example, Dr. Cotsen may share your protected health information between or among Dr. Cotsen’s personnel to assist your health care providers in treating you.
For Payment. Dr. Cotsen may use and disclose medical information about you so that Dr. Cotsen can get paid for the treatment and services you receive at Dr. Cotsen’s medical practice. For example, Dr. Cotsen may need to give information to your health plan or to Medicare program about treatment you receive at Dr. Cotsen so that they will pay Dr. Cotsen or reimburse you for your care. Dr. Cotsen may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.
For Health Care Operations. Dr. Cotsen may use and disclose medical information about you to carry out activities that are necessary for Dr. Cotsen’s operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, Dr. Cotsen may use medical information to review treatment and services provided at Dr. Cotsen’s medical practice or to evaluate the performance of its staff and contractors in caring for you.
To Individuals or Family Members Involved in Your Health Care. Unless you object, Dr. Cotsen may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. Dr. Cotsen may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.
For Appointment Reminders. Dr. Cotsen reserves the right to contact you, in a manner permitted by law, with appointment reminders or information about treatment alternatives and other health related benefits that may be appropriate for you.
Emergencies. Dr. Cotsen may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, Dr. Cotsen will use his professional judgment to decide whether this disclosure is in your best interest.
For Fundraising Activities. Dr. Cotsen may use medical information about you to contact you about Dr. Cotsen’s sponsored activities including fundraising events. Dr. Cotsen will only use contact information such as your name, address, and phone number.
As Required By Law. Dr. Cotsen will disclose your health information when required to do so by federal, state or local law.
Workers’ Compensation. Dr. Cotsen may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
For Public Health Activities. Dr. Cotsen may disclose medical information about you for public health activities. These purposes generally include the following: (1) to prevent or control disease, injury, or disability; (2) to report deaths; (3) to report abuse or neglect of children, elders, and dependent adults; (4) to report reactions to medications or problems with products; (5) to notify people of recalls of products they may be using; and (6) to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.
For Health Oversight Activities. Dr. Cotsen may disclose medical information about you to a health oversight agency for activities authorized by law.
For Lawsuits and Disputes. Dr. Cotsen may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.
Disclosure to Law Enforcement. If asked to do so by law enforcement and as authorized or required by law, Dr. Cotsen may release medical information: (1) to identify or locate a suspect, fugitive, material witness, or missing person; (2) about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) about a death suspected to be the result of criminal conduct; (4) about criminal conduct at the Owner; and (5) in case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Decedents. Dr. Cotsen may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Dr. Cotsen may also release medical information about you to funeral directors. Dr. Cotsen may also release information to any individual known to Dr. Cotsen as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.
For Specialized Government Functions. Dr. Cotsen may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.
Information About Inmates/Individuals in Custody. If you are an inmate or under the custody of a law enforcement official, Dr. Cotsen may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.
Disclosure For Threats to Health and Safety. In certain circumstances, Dr. Cotsen may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
SPECIAL PROVISIONS RELATED TO PATIENT PRIVACY
Psychotherapy Notes. Dr. Cotsen will not release any psychotherapy notes without a specific authorization from you that allows Dr. Cotsen to release the notes.
Marketing. Dr. Cotsen will not release your medical information for marketing purposes without an authorization from you.
Sale of Medical Information. Dr. Cotsen will not sell your medical information without an authorization from you.
HIV/AIDS Test Results. Dr. Cotsen will not disclose the results of an HIV/AIDS test unless you give Dr. Cotsen specific written authorization. Dr. Cotsen may disclose HIV/AIDS test results without your specific authorization as required by state or federal reporting laws.
You have the following rights regarding your medical information. In order to exercise these rights, you must contact the HIPAA Privacy Officer at Dr. Cotsen’s medical practice. You may be asked to submit a written request. The HIPAA Privacy Officer may be contacted using the following information:
Medical Practice of Adam Cotsen, M.D.
Attn: HIPAA Privacy Officer
116 North Robertson Blvd.
Los Angeles, CA 90048
Phone: (310) 659 -8640
Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.
Amendment. If you feel that medical information about you is incorrect or incomplete, you may ask Dr. Cotsen to amend the information.
Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures that Dr. Cotsen may have made of your medical information.
Right to Request Restrictions. You have the right to request a restriction or limitation on medical information that Dr. Cotsen uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that Dr. Cotsen may disclose to family members or friends involved in your care.
Request Confidential Communications. You have the right to request that Dr. Cotsen communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.
Receive a Copy. You have the right to obtain a copy of this notice.
CHANGES TO THIS NOTICE
Dr. Cotsen reserves the right to change the terms of this Notice at any time. Dr. Cotsen reserves the right to make the revised or changed notice effective for medical information Dr. Cotsen already has about you as well as any information Dr. Cotsen receives in the future. Dr. Cotsen will post a copy of the current Notice. The Notice will contain an effective date.
QUESTIONS AND COMPLAINTS
If you have any questions or believe that your privacy rights have been violated, you may contact Dr. Cotsen ‘s HIPAA Privacy Officer in person or mail a written summary of your concern to the address listed above.
You may also file a complaint with the Department of Health and Human Services as follows:
Michael Leoz, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Customer Response Center: (800) 368-1019
Fax: (202) 619-3818
TDD: (800) 537-7697
You will not be penalized or retaliated against for filing a complaint.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide Dr. Cotsen permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission Dr. Cotsen will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if Dr. Cotsen has already acted in reliance on your permission. You understand that Dr. Cotsen is unable to take back any disclosure Dr. Cotsen has already made with your permission and that Dr. Cotsen is required to retain its records of the care that Dr. Cotsen provided to you.