Notice of Privacy Practices
HIPAA Privacy Practices
HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: August 13, 2024
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices (“Notice”) apply to Dr. Samuel Girguis, its affiliates, and its employees. Dr. Samuel Girguis will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Dr. Samuel Girguis. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION:
Authorization and Consent: Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health information as necessary for your treatment. Psychiatrists, doctors, nurses, and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc.
Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your mental health treatments and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation, and licensing, etc. For instance, we may use and disclose your deidentified protected health information for purposes of improving clinical treatment and patient care.
Individuals Involved In Your Care: We may from time to time disclose your protected health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as billing, auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of these outside persons or organizations who assist us with my health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information.
Appointments and Services: We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voicemail or sent to a particular address, we will accommodate reasonable requests. With such a request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such a request. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below.
Research: In limited circumstances, we may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of your information.
Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:
Any purpose required by law;
Public health activities as required by law in connection with public health investigations;
If we suspect child abuse or neglect we are mandated by law to report this to Child Welfare. Similarly, if we suspect an elderly or dependent adult to be a victim of abuse or neglect; we are mandated by law to report this to Adult Protective Services.
To your employer when we have provided health care to you at the request of your employer;
To a government oversight agency conducting audits, investigations, civil or criminal proceedings;
Court order or court-ordered subpoena;
To law enforcement officials as required by state law if we believe you have been the victim of abuse or neglect. We will only make this disclosure if you agree or when required or authorized by law;
To coroners and/or funeral directors consistent with law;
To workers' compensation agencies for workers' compensation benefit determination;
To first responders in the event of a medical or life-threatening emergency.
DISCLOSURES REQUIRING AUTHORIZATION:
Progress Notes: We must obtain your specific written authorization prior to disclosing any progress notes unless otherwise permitted by law. However, there are certain purposes for which we may disclose progress notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment, or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.
Genetic Information: We must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment, or health care operations purposes. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law.
Marketing: We must obtain your authorization for any use or disclosure of your protected health information for marketing.
Sale of Protected Information: We must obtain your authorization before receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for:
Public health activities;
Research purposes, provided that we receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes;
Treatment and payment purposes;
Health care operations involving the sale, transfer, merger, or consolidation of all or part of our business and for related due diligence;
Payment we provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on our behalf (or the subcontractor undertakes on behalf of a business associate) and the only remuneration provided is for the performance of such activities;
Providing you with a copy of your health information or an accounting of disclosures;
Disclosures required by law;
Disclosures of your health information for any other purpose permitted by and in accordance with the Privacy Rule of HIPAA, as long as the only remuneration we receive is a reasonable, cost-based fee to cover the cost to prepare and transmit your health information for such purpose or is a fee otherwise expressly permitted by other law; or
Any other exceptions allowed by the Department of Health and Human Services.
RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:
Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. If not readily producible, we may provide the records in a standard electronic format or a readable hard copy format. All requests for access must be made in writing and signed by you or your representative. We may charge you a fee for the costs of copying, mailing, or other supplies associated with your request as permitted by state law. You may obtain a request form from Dr. Samuel Girguis at the address below.
Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction request. If an amendment or correction you request is made by us, we may also notify others who work with us that the change has been made. If we do not agree to amend your information, you may submit a written statement of disagreement which will be included in your medical record, and we may provide a rebuttal to your statement.
Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free; you will be charged a fee of $25 for each subsequent accounting you request within the same 12-month period. You may obtain an accounting request form from Dr. Samuel Girguis at the address below.
Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on certain uses and disclosures of your protected health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. If we terminate the agreement to the restriction, we will notify you of such termination. In this case, your protected health information will only be used or disclosed as permitted by the Privacy Rule of HIPAA. You also have the right to restrict certain disclosures of your protected health information to a health plan where you have paid out-of-pocket in full for the health care item or service.
Breach Notifications: If there is a breach of your unsecured protected health information, we will notify you of the breach as required by law. You have the right to receive notifications of breaches of your unsecured protected health information.
Paper Copy of Notice: As a patient, you have the right to obtain a paper copy of this Notice of Privacy Practices, even if you agreed to receive such notice electronically. You may request a copy of this Notice at any time by contacting Dr. Samuel Girguis at the address below.
Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with Dr. Samuel Girguis or with the Office for Civil Rights in the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION:
If you have questions or need further assistance regarding this Notice, you may contact Dr. Samuel Girguis using the contact information provided below:
Dr. Samuel Girguis
Office Address - 33 S Catalina Ave, Pasadena, CA 91106, Suite 204