This notice is to inform you of our privacy practices and how we maintain the confidentiality of your “protected health information” (PHI). We understand that this information is personal and completely confidential so this policy is designed to explain to you how we handle your information.

Your confidentiality is maintained by restricting access only to employees who need access to your PHI in order to process services. Also we have implemented appropriate physical, electronic and procedural safeguards to protect your PHI against any unauthorized use or disclosure. Our staff is required to complete and annually review a training program designed to protect your PHI.

Although there are many safeguards to protect your PHI, there are some instances where Federal and state laws allow us to use/disclose your information without your consent. These are:

 1.  To provide your health care services
 2.  To bill and collect payments for the health care services provided
 3.  To provide you with treatment alternatives
 4.  To inform you about health benefits and services
 5.  To remind you about your appointments
 6.  To complete health care operations such as to resolve an appeal or grievance
 7.  When required by law
 8.  For public health activities
 9.  For reports about child and other types of abuse or neglect or domestic violence
10. For health oversight activities
11. For lawsuits and other legal disputes
12. For law enforcement purposes
13. To report to coroners, medical examiners, or funeral directors
14. For tissue or organ donations
15. For research
16. To avert a serious threat to the health or safety of you or others
17. For national security and intelligence/military activities
18. In connection with services provided under worker’s compensation laws
19. To family members or other persons who are involved in your care or payment of care
20. To create a directory that includes your name, your location at the facility, your general condition and your religious preference when you are in an affiliated hospital.

You may agree or object to this disclosure. If you cannot agree or object because you are incapacitated or otherwise unavailable, we will use our professional judgment.

If you are a parent, you may control your minor child’s PHI. There are some cases where we are permitted or even required by law to deny your access to your child’s PHI, such as when your child can legally consent to medical services without your permission.

There are some types of PHI, such as HIV test results or mental health information, which are protected by stricter laws. However, even this PHI may be used or disclosed without your written authorization if required or permitted by law.

All other uses and disclosures of your PHI require your written authorization.

If you need an authorization form, we will send you one for you or your personal representative to complete. When you receive the form, please fill it out and send it to the address listed at the bottom of this notice.

You may revoke or modify your authorization at any time by writing to us at the same address. Please note that your revocation or modification may not be effective in some circumstances, such as when we have already taken action relying on your authorization.

You also have the right to review and copy any of your PHI that we possess. If you wish to see your PHI, please write to us and we will tell you when and where you can review your PHI in our possession within our normal business hours. If you would like a copy of the information we have, please write to us at the same address. If we provide you with a copy, we may charge a reasonable administrative fee for copying your PHI to the extent permitted by applicable law. If we deny your request for review or copy of your PHI, we will explain the reason in writing. If we do not have your PHI, but know who does, we will tell you whom to contact. If you wish to have your PHI corrected or updated, please write to us and tell us what you want changed and why. We will respond to you in writing, either accepting or denying your request. If we deny your request, we will explain why. You may also send us an addendum that is no longer than 250 words in length for each item you believe is incorrect. Please clearly indicate that you want the addendum to be included in your PHI. We will attach your addendum to the record(s) of your PHI. Your amended PHI will be available for your review upon request.

You have the right to request an accounting of certain disclosures that we make of your PHI by writing to us. Please note that certain disclosures, such as those made for treatment, payment, or health care operations, need not be included in the accounting we provide to you. We will respond to your request within a reasonable period of time, but no later than 60 days after we receive your written request.

You have the right to request and receive a paper copy of this Notice.

You have the right to request restrictions on how we use and disclose your PHI for our treatment, payment, and health care operations. All requests must be made in writing. Upon receipt, we will review your request and notify you whether we have accepted or denied your request. Please note that we are not required to accept your request for restrictions. Your PHI is critical for providing you with quality health care. We believe we have taken appropriate safeguards and internal restrictions to protect your PHI, and that additional restrictions may be harmful to your care.

You have the right to request that we provide your PHI to you in a confidential manner. For example, you may request that we send your PHI by an alternate means (e.g., sending by a sealed envelope, rather than a post card) or to an alternate address (e.g., calling you at a different telephone number, or sending a letter to you at your office address rather than your home address). We will accommodate any reasonable requests, unless they are administratively too burdensome, or prohibited by law.

We must follow the privacy practices set forth in this Notice while in effect. If you have any questions about this Notice, wish to exercise your rights, or file a complaint, please direct your inquiries to the address listed at the bottom of this notice. You may contact your Health Plan or the California Department of Managed Care with your concerns as well. You also have the right to directly complain to the Secretary of the United States Department of Health and Human Service. We will not retaliate against you for filing a complaint against us.

We will use and disclose your PHI to the fullest extent authorized by law. We reserve the rights as expressed in this Notice. We reserve the right to revise our privacy practices consistent with the law and make them applicable to your entire PHI we possess, regardless of when it was received or created. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Unless law requires the changes, we will not implement material changes to our privacy practices before we revise our Notice. You may request updates to this Notice at any time.

This Notice is effective: November 1st, 2003
Willow Urgent Care Medical Center
2704 East Willow Street
Signal Hill, Calif. 90755
Attn: Privacy Officer