Our office is dedicated to providing service with respect for human dignity. Protecting your privacy and your healthcare information is fundamental in the course of our relationship. This notice will remain in effect until it is replaced or amended by changes in law. We gather personal information and health information in several ways. This information is used for treatment, payment and healthcare operations:
• Information we receive from you;
• Information we receive from other healthcare providers; and
• Information we receive from third party payers.
You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for the treatment, payment, and healthcare operations.
You may authorize us to use protected health information for any purpose or to disclose your health information to any personal representation you choose by submitting the authorization in writing.
This office will not use your health information for marketing communications without your written authorization. However, this office may send birthday cards, newsletters and appointment reminders, by telephone calls, or mail.
This office may use or disclose your protected health information when required by law.
1) Upon written request you have the right to access, review or receive copies of your healthcare records. There is a copy fee of $15. Please allow 10 working days for processing.
2) Upon written request you have the right to receive a list of items this office disclosed about your healthcare information.
3) You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information.
4) You have the right to request that we amend your Protected Health Information; the request must be in writing.
5) You have the right to receive all notices in writing.
If you have any questions, complaints or want more information, please contact us:
455 Arkansas Street
San Francisco, CA 94107
(415) 282-9603 x232
Send written complaints to the U.S. Department of Health & Human Services at:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Telephone: (202) 619-0257
Toll Free: (877) 696-6775
*Please be aware that mail sent to the Washington D.C area offices takes an additional 3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.