Jeff Sarkozi, MD, FRCPC, FACR Fibromyalgia Polypain Arthritis Center 801 North Tustin Avenue Suite 503 Santa Ana, California 92705 Phone: 714-973-4636 www.fmpolypain.com
Your Information. Your
Rights. Our Responsibilities.
describes how medical information about you may be used and disclosed and how
you can get access to this information. Please
review it carefully.
When it comes to
your health information, you have certain rights. This section explains your rights and some of
our responsibilities to help you.
Get an electronic or
paper copy of your medical record •
ask to see or get an electronic or paper copy of your medical record and other
health information we have about you. Ask us how to do this. •
provide a copy or a summary of your health information, usually within 30 days
of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your
medical record •
ask us to correct health information about you that you think is incorrect or
incomplete. Ask us how to do this.
We may say
“no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications •
You can ask us to contact you in a
specific way (for example, home or office phone) or to send mail to a different
We will say “yes” to all reasonable
Ask us to limit what we use or share
You can ask us not to use or share certain
health information for treatment, payment, or our operations. We are not
required to agree to your request, and we may say “no” if it would affect your
If you pay for a service or health care
item out-of-pocket in full, you can ask us not to share that information for
the purpose of payment or our operations with your health insurer. We will say
“yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the
times we’ve shared your health information for six years prior to the date you
ask, who we shared it with, and why.
We will include all the disclosures except
for those about treatment, payment, and health care operations, and certain
other disclosures (such as any you asked us to make). We’ll provide one
accounting a year for free but will charge a reasonable, cost-based fee if you
ask for another one within 12 months.
Get a copy of this privacy notice You
can ask for a paper copy of this notice at any time, even if you have
agreed to receive the notice electronically. We will provide you with a
paper copy promptly.
Choose someone to act for you •
If you have given someone medical power of
attorney or if someone is your legal guardian, that person can exercise your
rights and make choices about your health information. •
We will make sure the person has this
authority and can act for you before we take any action.
File a complaint if you feel your rights
are violated •
You can complain if you feel we have
violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S.
Department of Health and Human Services Office for Civil Rights by sending a
letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling
1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. •
We will not retaliate against you for
filing a complaint.
For certain health
information, you can tell us your choices about what we share. If you have a clear preference for how we share
your information in the situations described below, talk to us. Tell us what
you want us to do, and we will follow your instructions.
In these cases, you
have both the right and choice to tell us to:
Share information with your family, close
friends, or others involved in your care •
Share information in a disaster relief
Include your information in a hospital
If you are not able to
tell us your preference, for example if you are unconscious, we may go ahead
and share your information if we believe it is in your best interest. We may
also share your information when needed to lessen a serious and imminent threat
to health or safety.
In these cases we never share your
information unless you give us written permission: •
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising
efforts, but you can tell us not to contact you again.
Our Uses and
How do we typically use or share your
We typically use or
share your health information in the following ways.
Treat you We can use your health information and share it with other
professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your
overall health condition.
Run our organization We can use and share your health information to run our practice,
improve your care, and contact you when necessary.
Example: We use health information about you to manage
your treatment and services.
Bill for your services We can use and share your
health information to bill and get payment from health plans or other
Example: We give information about you to your health
insurance plan so it will pay for your services.
else can we use or share your health information? We are allowed
or required to share your information in other ways – usually in ways that
contribute to the public good, such as public health and research. We have to
meet many conditions in the law before we can share your information for these
purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues We can share health information about you for certain situations such
with product recalls
adverse reactions to medications
suspected abuse, neglect, or domestic violence
or reducing a serious threat to anyone’s health or safety
Do research We can use or share your information for health research.
Comply with the law We will share information about you if state or federal laws
require it, including with the Department of Health and Human Services if
it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation
can share health
information about you with organ procurement organizations.
Work with a medical examiner or funeral
health information with a coroner, medical examiner, or funeral director
when an individual dies.
Address workers’ compensation, law enforcement,
and other government requests We can use or share health information about you:
workers’ compensation claims
enforcement purposes or with a law enforcement official
health oversight agencies for activities authorized by law
special government functions such as military, national security, and
presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
required by law to maintain the privacy and security of your protected health
let you know promptly if a breach occurs that may have compromised the privacy
or security of your information.
follow the duties and privacy practices described in this notice and give you a
copy of it.
not use or share your information other than as described here unless you tell
us we can in writing. If you tell us we can, you may change your mind at any
time. Let us know in writing if you change your mind.
information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all
information we have about you. The new notice will be available upon request,
in our office, and on our web site.
Date of this Notice: September 1, 2014
Official: Jeff Sarkozi, MD, FRCPC, FACR, Fibromyalgia Polypain Arthritis Center,
801 North Tustin Avenue, Suite 503, Santa Ana, California 92705, Phone: