HIPAA Privacy Notice – Patient

"Health Insurance Portability and Accountability Act"

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.

The Federal Government has required that your medical records remain private, confidential, and absolutely not available to anyone without your expressed written consent. Our medical record of your care remains the physical property of Alpine Allergy and Asthma Associates Inc. The State of California supports this law.  Forms are used for you to authorize, in writing, the release of a copy of your specific medical records to another physician, medical practice or to an insurance company.

Health Care Operations

There remains certain instances, where, in the process of delivering good medical care to our patients, specific disclosure of information becomes necessary and will be conducted by medical and administrative professionals within this practice, without expressed written permission of each and every specific incident by you. Some examples include:

• Calling/faxing/electronically communicating to your pharmacy for new prescription or renewal
• Calling your insurance carrier for billing and/or reimbursement purposes
• Faxing your insurance carrier with documentation of care
• Calling/faxing/e-mailing your Primary Care Physician (PCP) with results of care or questions
• Handling of the mail, newsletters, claims, bills, referrals
• Requesting that the office/reception staff call you to schedule an appointment, acquire a referral, or to inform you about medication that may have to be held for testing or procedures
• Medical staff informing you of potential treatment alternatives or options which may include, but not be limited to normal lab, pathology or x-ray results
• Inform you of health-related benefits or services that may be of interest to you
• Verbal or written correspondence with insurance companies
• Routine inter-office communication between professional staff of this specialty practice to effectively manage your medical care, and with the administrative staff to coordinate referrals, send appointment reminders, file & store medical records, order/receive antigen, submit claims and manage accounts billing, co-pays
• Messages may be left on your home message machine, your work voice mail or on your cell phone
• PHI utilized to conduct Quality programs to improve activities or for compliance reviews
• Employee training programs
• Accreditation, licensing, certification of activities
• You may restrict disclosure of any pat of your Private Medical Information from within this practice to any outside source or recipient, where not allowed by law: Federal, State or by Court Order.

Your Rights under the Law:

• You have the right to expect that we will respect and honor your personal medical information.
• You have the right to request a copy of your medical record for yourself and/or sent to another physician.
• You have the right to discuss any and all information contained in your medical record with your provider of care in a private environment.
• You have the right to complain to the Privacy Officer regarding how your medical information is guarded, handled and released (or not released) under the tenants of the law.
• You have the right to express concerns about the law and its limitations to the US Government Department of Health and Human Services.

Practice Duties

It is our responsibility to guard and maintain information about you and your health in a very private manner. This information will be disclosed within the practice on a "needs to know" basis, and then kept confidential for your assurance that we comply with the Federal, State, and local laws on "Confidentiality of Medical Information."

Patient Name ___________________________________________________________________________

ACKNOWLEDGEMENT

I, ____________________________________ (patient, responsible party),
Acknowledge that I have received a copy of Alpine Allergy and Asthma
Associates Inc’s (the practice’s) "HIPAA Privacy Notice-Patient" document
regarding protection of Personal Health Information.

Patient’s or Responsible Party’s Signature ____________________________

Date ________________________________