Notice of Privacy Practices

1. Who this notice applies to

This Notice of Privacy Practices applies to LAC Medical Inc., located at 5300 Lennox Avenue, Suite 105, Bakersfield, California 93309. It describes how we may use and share information about your health care, and how you can get access to this information. We are required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices with respect to that information, and to follow the terms of the notice currently in effect.

2. What is "protected health information"

Protected health information ("PHI") is information about your health, the health care you receive, and payment for that care that can be linked to you. It includes information we create or receive in any form — written, spoken, or electronic — that identifies you as a patient. PHI includes, for example: your name, address, phone number, date of birth, Social Security number, insurance information, diagnoses, test results, treatment plans, and visit notes.

3. How we may use and share your information

Federal law allows us to use and share your PHI for the following purposes without your written authorization:

For your treatment

We may use and share your information to provide, coordinate, or manage your medical care. Example: if we refer you to a specialist for a procedure, we may share your relevant records with that specialist so they can take care of you.

For payment

We may use and share your information so we can bill and receive payment for the care we provide. Example: we may share information with your insurance company to confirm a procedure is covered before we provide it.

For our health care operations

We may use and share your information to run our practice, improve the care we provide, and contact you for follow-up. Examples: reviewing the quality of our services, training staff, scheduling reminders, or contacting you about appointments and prescriptions.

4. Other uses permitted by law

Federal and state law allow or require us to share your information in certain other situations without your written authorization. These include:

• When required by law — when federal, state, or local law requires the disclosure.
• Public health activities — to public health authorities for things like preventing disease, reporting births and deaths, tracking adverse reactions to medications, or notifying people who may have been exposed to a communicable disease.
• Victims of abuse, neglect, or domestic violence — to a government authority authorized by law to receive such reports.
• Health oversight activities — to government agencies for audits, investigations, inspections, and licensure.
• Lawsuits and legal proceedings — in response to a court order, subpoena, or other lawful process.
• Law enforcement — in limited situations, such as in response to a warrant, to identify or locate a suspect, or to report a crime that occurred on our premises.
• Coroners, medical examiners, and funeral directors — to perform their legally authorized duties.
• Organ and tissue donation — to organizations that handle procurement, banking, or transplantation.
• Research — when the research has been approved by an Institutional Review Board with appropriate protections for your information.
• To avert a serious threat to health or safety — when disclosure is needed to prevent or lessen a serious and imminent threat.
• Specialized government functions — for military, national security, or protective services activities.
• Workers' compensation — to comply with workers' compensation laws.
• Inmates and correctional institutions — to provide care and protect the health and safety of inmates and others, when applicable.

5. Uses that require your written authorization

For most uses and disclosures other than those listed above, we will ask for your written authorization before we use or share your information. Specifically, we will not use or share the following without your written authorization, except as the law allows:

• Marketing — most uses of your information for marketing purposes.
• Sale of your information — we will never sell your information.
• Psychotherapy notes — most uses and disclosures of psychotherapy notes (separate from your general medical record).
• Other uses not described in this notice.

If you give us authorization to use or share your information, you can revoke that authorization in writing at any time. Your revocation will not apply to information we have already used or shared in reliance on your prior authorization.

6. Your rights regarding your information

You have the following rights with respect to your protected health information:

The right to inspect and copy your information

You have the right to see and get a copy of your medical record and billing record in most cases. We may charge a reasonable fee based on the actual cost of producing the copy. You can make this request in writing, addressed to the Privacy Officer at the contact information below.

The right to request an amendment

If you believe information in your record is incorrect or incomplete, you can ask us to amend it. Submit your request in writing to the Privacy Officer, with the reason for the request. We may decline your request in certain situations, but we will tell you our reason in writing if we do.

The right to request restrictions on uses and disclosures

You have the right to ask us to limit how we use or share your information for treatment, payment, or operations. We are not required to agree to your request unless the disclosure is to a health plan for payment or operations, and the information relates entirely to a service you paid for out of pocket in full. We will tell you if we cannot agree.

The right to request confidential communications

You have the right to ask us to communicate with you in a specific way (for example, only at your home phone, or only by mail). We will accommodate reasonable requests.

The right to an accounting of disclosures

You have the right to ask for a list of certain disclosures we have made of your information outside of treatment, payment, and operations during the previous six years. The first request in any twelve-month period is free; we may charge a reasonable fee for additional requests.

The right to a paper copy of this notice

You have the right to a paper copy of this notice at any time, even if you have agreed to receive it electronically. Ask the front desk and we will give you one.

The right to be notified of a breach

If a breach occurs that may have compromised the privacy or security of your information, we will notify you as required by law.

7. Our responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

8. Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website at lacmedicine.com/hipaa-notice.html. The effective date at the top of this notice will be updated whenever we make changes.

9. How to file a complaint

If you believe your privacy rights have been violated, you can file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

Complaints to us

Contact our Privacy Officer using the information below. You may file a complaint orally or in writing.

Complaints to the federal government

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:

• By mail: 200 Independence Avenue SW, Washington, D.C. 20201
• By phone: 1-877-696-6775 (toll-free)
• Online: www.hhs.gov/ocr/complaints/

10. Who to contact

This notice is provided pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 164 Subpart E. Language is adapted from the U.S. Department of Health and Human Services Model Notice of Privacy Practices.