HIPAA COMPLIANCE PRIVACY RULE FORM

Please read and submit at the bottom of the page. All information is kept private a secure. This information is made available upon request by a patient.

Notice of Privacy Practices – Date of Last Revision: April 30, 2019

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.

The terms of this Notice of Privacy Practices apply to Stem Cell Doctors of Beverly Hills operating as a health care provider who are licensed health care professionals seeing and treating patients. All such entities and persons will share your personal, health and medical information as necessary to perform treatment, payment and health care operations as allowed by law.

Uses and Disclosures
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 laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage, such as your 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.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

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 your information that occurred before you notified us of your decision to revoke your authorization.

HIPAA COMPLIANCE PLAN – PRIVACY RULE

Additional Uses of Information
Appointment Reminders: Your health information may be used by staff to send you appointment reminders.

Information and Treatments: Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health-related services that we believe may interest you.

Individual Rights: You have certain rights under the federal privacy standards. These include the following and are explained in greater detail in the PATIENT RIGHTS section of this notice:

∙ 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 send 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.

Duties of the Practice: 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 are also 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. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information: You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information in writing. You may obtain a form to request access to your records by contacting our receptionist or privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Complaints: If you would like to submit a comment or complaint regarding our privacy practices, you can do so by sending a letter outlining your concerns to: Zena DelVecchio, Compliance Officer: 416 N. Bedford Drive – Suite 400, Beverly Hills, CA 90210

If, at any point, you feel that your privacy rights have been violated, please do not hesitate to 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.

Contact Person: The name and address of the person you may contact for further information concerning our privacy practices is:
Zena DelVecchio, Compliance Officer
416 N. Bedford Drive – Suite 400
Beverly Hills, CA 90210
Telephone: 310.275.5698
Email: info@stemcelldocs.com

Effective Date: This Notice is effective on or after April 30, 2019.

PATIENT RIGHTS
THIS SECTION DESCRIBES YOUR RIGHTS AND THE OBLIGATIONS OF THIS PRACTICE REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

You may have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon proof of appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed.

To inspect and receive a copy of medical information that may be used to make decisions about you, you may contact the person listed on page three of this Notice in writing. If you request a copy of the information we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.

In certain limited situations, we may deny your request, such as when research is in progress. If we do, we will advise you in writing in a timely manner of our reasons for the denial and information on how you may have the denial reviewed. We will comply with the outcome of any such review.

Right to Amend: If you believe that medical information we have about you is incorrect or incomplete, you have the right to request that we correct the existing information or add the missing information. You have the right to request an amendment for as long as the information is kept by Stem Cell Doctors of Beverly Hills Inc. To request an amendment, you must provide the request in writing along with your reason for the request to the person listed in section V below. We will respond within 60 days of receiving your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if the medical information is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file a written statement of disagreement, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.

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 others.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose for treatment, payment or health care operations. You may not limit the uses and disclosures that we are legally required or allowed to make. You also have the right to request a limit on medical information we disclose about to (i) someone who is involved in your care or the payment for your care, like a family member or friend, (ii) information from the hospital’s patient directory; or (iii) information for fundraising purposes. For example, you could ask that we not use or disclose information about a procedure you had.

We may deny certain requests if we do agree to your request, we will comply with it unless the information is needed to provide you emergency treatment.

To request restrictions on the use or disclosure of your medical information, you may do so at the time you register for medical services. Your request must include (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).
You may also request such a restriction at any time contacting the person listed on page three of this Notice in writing.

A previously agreed to restriction may be terminated by you or Stem Cell Doctors of Beverly Hills, either orally or in writing. If we terminate the restriction, we can only use or disclose medical information we create or obtain after such restriction is terminated.

The Right to Request Confidential Communications: You have the right to ask that we send information to you to an alternate address (for example, if you want appointment reminders to not be left on an answering machine or if you want information sent to your work address rather than your home address) or by alternate means (for example, email instead of regular mail). We will agree to all reasonable requests so long as we can easily provide it in the format you requested. To request medical information sent to an alternative address or by other means, please contact the privacy officer listed on page three of this Notice.

The 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 by e-mail, you are still entitled to a paper copy. To obtain a paper copy of this Notice, please contact the privacy officer listed on page three of this Notice.

I have read and received a copy of this notice.