| The
privacy of your personal and health information is important to us. Please
review it carefully. |
| This notice
describes how medical information about you may be used and disclosed and how
you can get access to this information. |
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| Memorial
HealthCare IPA understands the importance of keeping your personal and health
information private. Personal and health information includes both medical
information and individually identifiable information, such as your name,
address, telephone number or social security number. This is a notice of
Memorial HealthCare IPA’s confidentiality and privacy practices, our legal
duties and your rights concerning your personal and health information. In
accordance with State and Federal law below are Memorial HealthCare IPA’s
privacy practices. While many of these practices are already in place, certain
provisions* take effect April 1, 2003, and will remain in effect unless
otherwise replaced or modified.
We may modify or change our privacy practices from time to time, particularly as
new laws and regulations become effective. Any changes will be effective for
the personal and health information that we maintain, even information in
existence before the change. If we materially modify our privacy practices, we
will provide you with a new notice advising you of these changes.
For more information about our confidentiality and privacy practices, or for
additional copies of this notice, please contact us using the information
listed at the end of this notice.
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| Memorial HealthCare IPA may use and disclose
your personal and health information, without your authorization, only in the
following ways: |
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Treatment: We may disclose your personal and health information to a provider
who requests this information to treat you.
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Payment: We may use and disclose your personal and health information to pay
claims for covered services provided to you.
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Health Care Operations: We may use and disclose your personal and health
information to conduct quality improvement activities, to engage in care
coordination and case management, and other similar activities.
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Scheduling Appointments: We may use and disclose you personal and health
information to schedule appointments with physicians and possibly remind you of
appointments.
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Plan Sponsors: We may disclose your personal and health information to the plan
sponsor to permit it to perform plan administration functions. Please see your
plan documents for a full explanation of limited uses and disclosures that the
plan sponsor may make of your personal and health information.
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Social Security Numbers: Your social security number is used for internal
identification purposes only. Your health plan ID number is used for
identification purposes between provider offices and health plans not your
social security number. It is the responsibility of your health plan to
establish an alternate ID number.
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Health & Wellness Information: We may use your personal and health
information to contact you with information about health related services,
appointment reminders or treatment alternatives. If you do not wish to receive
this type of information, you may request to opt-out of receiving this
information from Memorial HealthCare IPA by sending an email to
askullr@mhipa.com or calling the phone number (562) 981-9500. However, you will
still continue to receive general, non-personal information, such as Memorial
HealthCare IPA newsletters.
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Family and Friends: We may disclose your personal and health information to a
family member, friend or other person if you are unavailable to agree such as
in a medical emergency or disaster relief. We will disclose this information
only to the extent necessary to help with your health care or with payment for
you health care.
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Public Health and Safety: We may use and disclose your personal and health
information to the extent necessary to avert a serious and imminent threat to
your health or safety or the health or safety of others. We may disclose your
personal and health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, domestic violence or
other crimes.
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Required by Law: We will use or disclose your personal and health information
when we are required to do so by law.
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Process and Proceedings: We may disclose your personal and health information
in response to a court or administrative order, subpoena, discovery request or
other lawful process.
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Law Enforcement: We may disclose limited information to a law enforcement
official concerning the personal and health information of a suspect, fugitive,
material witness, crime victim or missing person. We may disclose the personal
and health information of an inmate or other person in lawful custody to a law
enforcement official or correctional institution under certain circumstances.
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Military and National Security: We may disclose to Military authorities the
personal information of Armed Forces personnel. We may disclose to authorized
federal officials personal and health information required for lawful
intelligence, counterintelligence and other national security activities.
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Access: You have the right to access your personal and health information. You
must make a request in writing to obtain access to your personal and health
information. You may obtain a form to request access by using the contact
information listed at the end of this notice. You have the right to obtain
copies of your personal and health information, with certain exceptions. You
may request that we provide copies in a format other than photocopies. Please
note that if you request copies, we will charge you a fee for each page.
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Disclosure Accounting: You have the right to an accounting of disclosures of
your personal and health information made by Memorial Health IPA. You can
request, in writing, that we provide you with an accounting of instances when
Memorial HealthCare IPA, or our business associates disclosed your personal and
health information for purposes other than treatment, payment, health care
operations, upon your written authorizations, and certain other activities. We
will begin maintaining disclosures for up to six years starting April 1, 2003.
If you request this accounting more than once in a 12-month period, then we may
charge you a reasonable, cost-based fee.
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Restriction Requests: You have the right to request restrictions on the use and
disclosure of your personal and health information. You can request, in
writing, that we place additional restrictions on the use or disclosure of your
personal and health information. We are not required to agree to these
additional restrictions, but if we elect to do so, we will abide by our
agreement (except in an emergency).
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Amendment: You have the right to amend your personal and health information.
You must make a request in writing to obtain an amendment. You must make a
request in written request must explain why the information should be amended.
If we amend the information for you, we will make reasonable efforts to inform
others of the amendment and to include the changes in any future disclosures of
that information. You can submit a written statement of disagreement to be
appended to the information you wanted amended.
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Electronic Notice: If you receive this notice on our website or by electronic
mail (e-mail), you are entitled to receive this notice in written form. Please
contact us using the information listed at the end of this notice to obtain
this notice in written form.
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If you want more information about our privacy practices or have questions or
concerns, please contact us using the information listed at the end of this
notice.
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If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we made about access to your personal and health
information you may complain to us using the contact information listed at the
end of this notice. You also may submit a written complaint to the U.S.
Department of Health and Human Services.
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| We support your right to protect the privacy
of your personal and health information. We will not retaliate in any way if
you choose to file a complaint with us or with the U.S. Department of Health
and Human Services. |
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Telephone: (562) 981-9500
Fax: (562) 988-8476
E-mail:askullr@mhipa.com
Address: 2525 Cherry Avenue, Suite 250, Signal Hill, CA. 90755
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