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Courtyard Medical Plaza Notice of Privacy Practices

Name: «Title» «First» «Last» Employee Number: «EmpNumber» Department: «Department» Date: January 1, 2018

Courtyard Medical Plaza

Notice of Privacy Practices

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.

In this notice we use the terms "we," "us," and "our" to describe Courtyard Medical Plaza (CMP).

WHAT IS "PROTECTED HEALTH INFORMATION (PHI)?"

Your PHI is health information that contains identifiers, such as your name, Social Security number, or other information that reveals who you are. For example, your medical record is PHI because it includes your name and other identifiers. If you are a Courtyard Medical Plaza member and also an employee of Courtyard Medical Plaza, PHI does not include the health information in your employment records.

ABOUT OUR RESPONSIBILITY TO PROTECT YOUR PROTECTED HEALTH INFORMATION

By law, we must:

1. protect the privacy of your PHI, 2. tell you about your rights and our legal duties with respect to your PHI, and 3. tell you about our privacy practices and follow our notice currently in effect.

We take these responsibilities seriously and, as in the past, we will continue to take appropriate steps to safeguard the privacy of your PHI.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

This section tells you about your rights regarding your PHI—for example, your medical and billing records. It also describes how you can exercise these rights.

YOUR RIGHT TO SEE AND RECEIVE COPIES OF YOUR PROTECTED HEALTH INFORMATION

In general, you have a right to see and receive copies of your PHI in designated record sets such as your medical record or billing records. If you would like to see or receive a copy of such a record, please write us. When you know the facility or medical office where you received your care, please write to us at that address. If you need that address please call 1-559-288-1660. However, if you don't know where the record that you want is located, please write to us at the Office of Privacy & Compliance, 1660 Alhandra Way, Granite Bay, CA 95517.

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Courtyard Medical Plaza Notice of Privacy Practices

YOUR RIGHT TO CHOOSE HOW WE SEND PROTECTED HEALTH INFORMATION TO YOU

You may ask us to send your PHI to you at a different address (for example, your work address) or by different means (for example, fax instead of regular mail). If the cost of meeting your request involves more than a reasonable additional amount, we are permitted to charge you our costs that exceed that amount.

YOUR RIGHT TO CORRECT OR UPDATE YOUR PROTECTED HEALTH INFORMATION

If you believe there is a mistake in your PHI or that important information is missing, you may request that we correct or add to the record. Please write us and tell us what you are asking for and why we should make the correction or addition. When you know the Courtyard Medical Plaza facility or medical office where you received your care, please write to us at that address. If you need that address, please call 1-559-288-1660. However, if you don't know where the record that you want is located, please write to us at the Office of Privacy & Compliance, 1660 Alhandra Way, Granite Bay, CA 95517.

YOUR RIGHT TO AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION

You may ask us for a list of our disclosures of your PHI. Write to the Coordinator of Privacy and Compliance, Office of Privacy & Compliance, 1660 Alhandra Way, Granite Bay, CA 95517. The list we give you will include disclosures made in the last six years, unless you request a shorter time or if less than six years have passed since April 14, 2005. For example, if you requested a list of disclosures on April 14, 2009, the list would cover only two years.

YOUR RIGHT TO REQUEST LIMITS ON USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

You may request that we limit our uses and disclosures of your PHI for treatment, payment, and health care operations purposes. We will review and consider your request. You may write to the Courtyard Medical Plaza facility or medical office where you received your care for consideration of your request. If you need that address please call 1-559-288-1660. However, if you don't know where the record that you want is located, please write to us at the Office of Privacy & Compliance, 1660 Alhandra Way, Granite Bay, CA 95517.

YOUR RIGHT TO RECEIVE A PAPER COPY OF THIS NOTICE

You also have a right to receive a paper copy of this notice upon request. SO LU

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