Notice of Privacy Practices
Consent to the Use and Disclosure of Health Information
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.
Elite Performance & Rehabilitation Center originates and maintains paper and/or electronic records describing our patient’s diagnosis, health history, treatment and future plans for medical care.
Uses and Disclosures: We will use your protected health information (PHI) for the purpose of treatment, payment and health care operations.
• We will disclose health information as a means of communication to other providers who have referred you for services or are involved in your care.
• Your insurance company may use your information for medical records review purposes. This may be to determine that your care was necessary so payment can be obtained for services rendered. We will be providing them with this information.
• The utilization of your records to monitor the quality of care being given at our facility.Uses and Disclosures required by law;
The federal health information privacy regulations either permit or require us to use or disclose your PHI in the following ways:
• In an emergency situation when you may not be able to express yourself
• Court order or subpoena
• Health oversight agencies to report diseases or adverse drug reactions.
• To avert serious threat to your health or safety or the health or safety of others.
• Workman’s compensation or other similar programs that provide benefits for work related injury or illness.Your authorization is required before your PHI may be used or disclosed by us for other purposes.
Your privacy rights:
Please read and understand the following rights and privileges list below.
• You may request restrictions on how your PHI is used; however,
we are not required to agree with your request. If we do agree,
we must abide by your request.
• You have the right to request confidential communication from
us at a location of your choosing. This request must be in writing.
• You may request a copy of your medical record. You must make this request in writing and we may charge a fee to cover the cost of copying and mailing.
• You have the right to request an amendment be made to your PHI, if you disagree with what it says about you. This request must be made in writing. If we disagree with you, we are not required to make this change. You do have the right to submit a written statement about why you disagree that will become part of your record. We may not amend parts of your medical record that we did not create.
• You may request an accounting of disclosures made over the past six years. These disclosures will not include those made for treatment, payment, or health care operations or for which we have obtained authorization.If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.
Elite Performance & Rehabilitation Center is required by federal health information privacy regulations to comply with maintaining the privacy of your PHI. These rules require us to provide you with this document, our Notice of Privacy Practices. We reserve the right to update this notice required by law in accordance with Section 164.520 of the Code of Federal Regulations. If we do update this notice at any time, you will receive a revised notice when you seek treatment from us.
If you would like more information about our privacy practices or to file a complaint you may contact:
Ceci Fort
Office Manager
Privacy Officer
5152 Hollister Avenue
Goleta, Ca. 93111
805-681-9108This notice was actively effective on April 2003.
