Summary Notice of Privacy Practices

THIS SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU AND/OR YOUR CHILD MAY BE USED, DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. Our office is committed to protecting the privacy of your medical information.

Your care and treatment is documented in a medical record. This medical record may be shared with other health care providers directly involved in your health care. We also share this information only to the extent necessary to collect payment for the treatment services we provide, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose your medical information for any other purpose without your permission.

You have the following rights regarding your medical information:

• To inspect and obtain a copy of your medical record, subject to some limited expectations.
• To add an addendum to or correct your medical record.
• To request an accounting of the provider’s disclosures of your medical information.
• To request restrictions on specific uses or disclosures of your medical information.
• To request that we communicate with you in a specific way.

We may use and disclose your medical information for the following purpose:

• To provide you with medical treatment and services.
• To bill and receive payment for the treatment and services you receive.
• For the purpose necessary to run the medical practice and assure that you receive the best quality care.
• To participate in research studies, subject to specific requirements and written consent.
• As required by law.

The following are additional circumstances where we may disclose your medical information without your authorization:

• For public health activities (e.g., reporting abuse or reactions to medications).
• To a health oversight agency, such as the California Department of Health Services.
• In response to a court or administrative order, subpoena, or warrant.
• To law enforcement officials in specific circumstances.
• To a coroner, medical examiner, or funeral director.
• To organizations that handle organ, eye, or tissue procurement or transplantation.

Our Notice of Privacy may be revised and updated as the need arises. Please contact our Privacy Officer for further information about our privacy practices or to receive a copy of our “Notice of Privacy Practices” at (650) 591-8501.

I have read and acknowledged the above Privacy Practice Notice

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