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Privacy Notice

NOTICE OF PRIVACY PRACTICES FOR DAVID J. PARKS, M.D.

I. 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.

II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).

We are legally required to protect the privacy of your health information. We call this information protected health information, or PHI for short, and it includes information that can be used to identify you that we’ve created or received about your past, present, or future health condition, the provision of healthcare to you, or the payment of this healthcare. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice.

However, we reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptly change this notice and post a new notice in the reception area. You can also request a copy of this notice from the contact person listed in Section VI, at any time and can view a copy of this notice on our Web Site at www.socalretina.com/html/privacy.html.

III. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH

INFORMATION

We use and disclose health information for many different reasons. For some of these uses or disclosures, we need specific authorization. Below, we describe the different categories of our uses and disclosures and give you some examples of each category.

A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. We may use and disclose your PHI for the following reasons:

1. For Treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care.

2. To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided for you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provided to you.

3. Services provided by business associates. There are some services provided in our office through contacts with business associates. Examples include certain diagnostic test such as fluorescein angiogram and fundus photos. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information.

4. For health care operations. We may disclose your PHI in order to operate this office. For example, we may use your PHI in order to evaluate the quality of health care services that you received. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we’re complying with the laws that affect us.

B. Certain Uses and Disclosures Do Not Require Your Authorization. We may use and disclose your PHI without your authorization for the following reasons:

1. When federal, state or local law, judicial or administrative proceedings, or law enforcement requires a disclosure. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims abuse, neglect, or domestic violence; when dealing with gunshot and other wounds; or when ordered in a judicial or administrative proceeding.

2. For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider.

3. For public health activities. As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

4. For purpose of organ donation. We may notify organ procurement organizations to assist them in organ, eye, or tissue donation and transplant.

5. For research purposes. We may disclose information to researchers when an institutional board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved their research.

6. To avoid harm. In order to avoid a serious threat to the health and safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent/lessen such harm.

7. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.

8. For workers’ compensation purposes. We may provide PHI in order to comply with workers’ compensation laws.

9. Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives or other health care services or benefits we offer.

C. Disclosures Require You to Have the Opportunity to Object

1. Disclosures to Family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

D. All Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, B, and C, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing to stop any future uses and disclosures (to the extent that we haven’t taken any action relying on the authorization).

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

You have the following rights with respect to your PHI:

A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask

that we limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.

B. The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you, to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). We must agree to your request so long as we can easily provide it in the format you requested.

C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. If we don’t have your PHI but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.

If you request copies of your PHI, we will charge you $.20 for each page. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance.

D. The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or health care operations, directly to you, to your family, or in our facility directory. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or before 4-14-03.

We will respond within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom the PMI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you $1 for each additional request.

E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may deny your request in writing if the PHI is correct and complete, not created by us, not allowed to be disclosed, or not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.

F. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of this notice

V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section VI below. You may send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Ave. S. W., Room 509F HHH Bldg., Washington D.C. 20201. We will take no retaliatory action against you if you file a complaint about our privacy practices.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact: Ana Huerta, Privacy Officer 42543 8th St W #105 Lancaster, CA 93534
Phone (310) 289-3666
, (661) 948-4361.

VII. EFFECTIVE DATE OF THIS NOTICE IS APRIL 14, 2003, in accordance with the Health Insurance Portability and Accountability Act of 1997, known as HIPAA.

04/14/03

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Great Gratitude to Dr. Parks and his staff for the gift of continued sight!  I HIGHLY COMMEND AND RECOMMEND THEM!!!

-Susan M.
Westwood, Los Angeles, CA