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.
Uses and Disclosures
For Treatment - Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of evaluations will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
For Payment - Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
For Health Care Operations - Your health information may be used as necessary to support the day-to-day activities and management of Advanced Arm Dynamics. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
For Law Enforcement - Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
For Public Health Reporting - Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization - Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Additional Uses of Information
For Appointment reminders - Your health information will be used by our staff to send you appointment reminders.
Information about treatments - Your health information may be used to send you information on the treatment and management of your medical condition or new technology that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you.
Individual Rights
You have certain rights under the federal privacy standards. These include:
- the right to request restrictions on the use and disclosure of your protected health information
- the right to receive confidential communications concerning your medical condition and treatment
- the right to inspect and copy your protected health information
- the right to amend or submit corrections to your protected health information
- the right to receive an accounting of how and to whom your protected health information has been disclosed
- the right to receive a printed copy of this notice
ADVANCED ARM DYNAMICS DUTIES
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in this notice.
RIGHT TO REVISE PRIVACY PRACTICES
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting (800) 323-6422.
COMPLAINTS
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Privacy Officer
Advanced Arm Dynamics, Inc.
123 W. Torrance Blvd., Suite 203
Redondo Beach, CA 90277
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
EFFECTIVE DATE
This Notice is effective on or after April 14, 2003.
COMPLAINTS
As listed below, health information privacy complaints may be filed with the Secretary of DHHS and should be addressed to him at the OCR (Office for Civil Rights) regional office that is responsible for matters relating to the Privacy Rule arising inthe state or jurisdiction where the covered entity is located. Complaints may also be filed via email at the address noted below.
Where to File Complaints Concerning Health Information Privacy
For complaints involving entities located in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, or Vermont:
Region I, Office for Civil Rights
US Department of Health and Human Services, Government Center
JFK Federal Building-Room 1875
Boston, MA 02203
Voice phone (617) 565-1340 | FAX (617) 565-3809 | TDD (617) 565-1 343
For complaints involving entities located in New Jersey, New York, Puerto Rico, or the Virgin Islands:
Region II, Office for Civil Rights
US Department of Health and Human Services
Jacob Javits Federal Building
26 Federal Plaza-Suite 3312
New York, NY 10278
Voice phone (212) 264-3313 | FAX (212) 264-3039 | TDD (2112) 264-2355
For complaints involving entities located in Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, or West Virginia:
Region Ill, Office for Civil Rights
Department of Health and Human Services
150S. Independence Mall West, Suite 372
Public Ledger Building
Philadelphia, PA 19106-9111
Main Line (215) 861-4441 | Hotline (800) 368-1019 | FAX (215) 861-4431 | TDD (215) 861-4440
For complaints involving entities located in Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, or Tennessee:
Region IV, Office for Civil Rights
US Department of Health and Human Services
Atlanta Federal Center
Suite 3B70, 61 Forsythe Street SW
Atlanta, GA 30303- 9809
Voice phone (404) 562-7886 | FAX (404) 562-7881 | TDD (404) 331-2867
For complaints involving entities located in Illinois, Indiana, Michigan, Minnesota, Ohio, or Wisconsin:
Region V7 Office for Civil Rights
Department of Health and Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
Voice phone (312) 886-2359 | FAX (312) 886-1807 | TDD (312) 353-5693
For complaints including entities located in Arkansas, Louisiana, New Mexico,
Oklahoma, or Texas:
Region VI, Office for Civil Rights
Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
Voice phone (214) 767-4056 | FAX (214) 767-0432 | TDD (214) 767-8940
For complaints involving covered entities located in Iowa, Kansas, Missouri, or
Nebraska:
Region VII, Office for Civil Rights
Department of Health and Human Services
601 East l2” Street—Room 248
Kansas City, MO 64106
Voice phone (816) 426-7278 | FAX (816) 426-3686 | TDD (816) 426-7065
For complaints involving covered entities located in Colorado, Montana, North Dakota, South Dakota, Utah, or Wyoming:
Region VIII, Office for Civil Rights
Department of Health and Human Services
1961 Stout Street--Room 1185 FOB
Denver, CO 80294-3538
Voice phone (303) 844-2024 | FAX (303) 844-2025 | TDD (303) 844-3439
For complaints involving covered entities located in American Samoa, Arizona, California, Guam, Hawaii, or Nevada:
Region IX, Office for Civil Rights
Department of Health and Human Services
50 United nations Plaza-Room 322
San Francisco, CA 94102
Voice phone (415) 347-8310 | FAX (415) 437-8329 | TDD (415)437-8311
For complaints involving covered entities located in Alaska, Idaho, Oregon, or Washington:
Region X, Office for Civil Rights
Department of Health and Human Services
2201 Sixth Avenue-Suite 900
Seattle, WA 98121-1831
Voice phone ((206) 615-2287 | FAX (206) 615-2297 | TDD (206) 615-2296
For all complaints filed by email, send to:
OCRComplaint@hhs.gov FOR FURTHER INFORMATION CONTACT:
Lester Coffer
Office for Civil Rights, Department of Health and Human Services
Mail Stop Room 506F
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Telephone number: (202) 205-8725