This notice applies to the Urban Med, located in Los Angeles, CA, and Urban Med satellite offices (including but not limited to Beverly Hills, CA). House Clinic. Urban Med has formed an organized health care arrangement for compliance with federal law regarding the privacy of your health information. If you have any questions about this notice, please contact:
408 W. 11th St
Los Angeles, CA 90015
OUR DUTIES REGARDING YOUR MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice will tell you about the ways in which Urban Med may use and disclose medical information about you. We also describe your right and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to:
Make sure that medical information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of our notice that is currently in effect.
HOW WE MAY USE & DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, researchers or other Urban Med personnel who are involved in taking care of you at Urban Med. Different departments of Urban Med also may share medical information about you in order to coordinate the different services you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside Urban Med who may be involved with your medical care after you leave Urban Med, such as family members, clergy, or others who use to provide services that are part of your care. Because Urban Med participates in an organized health care arrangement, they may share your medical treatment information with each other as necessary to carry out medical treatment duties of the organized health care arrangement.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at Urban Med may be billed and payment may be collected from you, an insurance company or a third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. Because Urban Med participates in an organized health care arrangement, they may share your medical information with each other as necessary to facilitate payment for duties of the organized health care arrangement.
For Health Care Operations. We may use and disclose medical information about you for Urban Med operations. These uses and disclosures are necessary to run Urban Med and make sure that all of our patients receive quality care. We may also combine medical information about many patients to decide what additional services Urban Med should offer, what services are not needed, and whether certain new treatment are effective. We may also disclose information to doctors, nurses, technicians, medical students, researchers and other Urban Med personnel for review and learning purposes. We may also combine the medical information we have with medical information from other health care providers to compare how we are doing and see where we can make improvement in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. Because Urban Med participates in and organized health care arrangement, they may share your medical information with each other as necessary to carry out health care operation duties of the organized health care arrangement.
Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps with payment for your care. We may also tell your family or friends your condition and that you are at Urban Med. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
As Required By Law. We will disclose medical information about you when required to do so by federal state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any discloure, however, would only be to someone able to help prevent the threat.
OTHER USES OF MEDICAL INFORMATION
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. If you revoke your permission that was obtained as a condition of obtaining insurance coverage, other law still allows the insurance company to contest a claim under the policy.
YOUR RIGHT REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the contact person(s) listed on the first page of this notice. A Request for Limitation Form for making your request will be provided upon request. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the contact listed on the first page of this notice
Right to Request Amendment. If you believe that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Urban Med.
To request an amendment, your request must be made in writing and submitted to the contact person(s) listed on the first page of this notice. In addition, you must provide a reason that supports your request.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this accounting of disclosures, you must submit your request in writing to the contact person(s) listed on the first page of this notice. Your request should indicate in what form you want the lists, and we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To obtain a paper copy of this notice, contact person(s) listed on the first page of this notice.
CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.
COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with Urban Med, submit the complaint in writing to the contact person(s) listed on the first page of this notice. All complaints must be submitted in writing. You will not be penalized for filing a complaint.