Acknowledgement of HIPAA Notice of Privacy Practices

PRIVACY POLICY

The law requires us to maintain the privacy of certain health information called "Protected Health Information" ("PHI"). Protected Health Information is the information that you provide us or that I create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When I use or disclose (share) your Protected Health Information, I am required to follow the terms of this Notice or other notice in effect at the time I use or share the PHI. Finally, the law provides you with certain rights described in this Notice. Furthermore, I am required to notify you following a breach of unsecured PHI.

Please note that if you choose to communicate with Dr. Rosenstock, outside of the provided HIPAA encrypted platforms or the telehealth video platform, such as but not limited to: by texting, phone call, FaceTime or other means, your health information will not be protected and may be subject to interception.

Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)

In many situations, I can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which I will describe in Section 4 below, I must have your written permission (authorization) to use and/or share your PHI. I do not need any type of permission from you for the following uses and disclosures:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice describes the privacy practice of Dr. Amber Rosenstock. It applies to the health care and related services you receive from Dr. Rosenstock. I may share your health information among your other providers to carry out our treatment, payment, and health care operations.

Uses and Disclosures for Treatment, Payment and Health Care Operations

I may use and share your PHI to provide "Treatment," obtain "Payment" for your Treatment, and perform our "Health Care Operations." These three terms are defined as:

Definitions

●  Treatment. I use and share your PHI to provide care and other services to you--for example, to diagnose and treat your injury or illness. In addition, I may contact you to provide appointment reminders or information about treatment options. I may tell you about other health-related benefits and services that might interest you. I may also share PHI with other doctors, nurses, and others involved in your care. I share your PHI with the pharmacy in order to prescribe medication to you.

●  Payment. I may use and share your PHI to receive payment for services that I provide to you. For example, I may share your PHI to request payment and receive payment, or coverage of your prescribed medications, from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care ("Your Payor") and to confirm that Your Payor will pay for health care, or your prescription medication. As another example, I may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.

●  Health Care Operations. I may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that I deliver. For example, I may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. However, you have the right to restrict disclosure to a health plan for healthcare services for which you pay in full out of pocket (excluding a deductible).

●  Business Associates. In addition, I may share PHI with certain others who help me with my activities, including those I hire to perform services.

Your Other Health Care Providers

I may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.

Disclosure to Relatives, Close Friends and Your Other Caregivers

I may share your PHI with your family member/relative, a close personal friend, or another person who you identify if I: (1) first provide you with the chance to object to the disclosure and you do not object; (2) reasonably infer that you do not object to the disclosure; or (3) obtain your agreement to share your PHI with these individuals. If you are not present at the time I share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, I may use our professional judgment to decide that sharing the PHI is in your best interest. I may also use or share your PHI to notify (or assist in notifying) these individuals about your location and general condition.

Public Health Activities

I am required or are permitted by law to report PHI to certain government agencies and others. For example, I may share your PHI for the following:

● to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability;

●  to report abuse and neglect to government authorities, including a social service or protective services agency, that are legally permitted to receive the reports;

●  to report information about products and services to the U.S. Food and Drug Administration;

●  to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of developing or spreading a disease or condition;

●  to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and

●  to prevent or lessen a serious and imminent threat to a person for the public's health or safety, or to certain government agencies with special functions such as the State Department.

Health Oversight Activities

I may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicare or Medicaid, are being followed.

Judicial and Administrative Proceedings

I may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Purposes

I may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.

Decedents

I may share PHI with a coroner or medical examiner as authorized by law. I may share your PHI with a family member who was involved in your care or payment for your care prior to death, unless such disclosure would be inconsistent with any prior expression you have communicated to us. Under federal, the privacy rights described herein will expire fifty years after your death.

Workers' Compensation

I may share your PHI as permitted by or required by state law relating to workers' compensation or other similar programs.

Disaster Relief

I may share your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

As Required by Law

I may use and share your PHI when required to do so by any other law not already referred to above.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION (AUTHORIZATION)

Use or Disclosure with Your Permission (Authorization)

For any purpose other than the ones described above, I may only use or share your PHI when you grant me your written permission (authorization). For example, you will need to give me your permission before I send your PHI to your life insurance company or disability insurance company.

Marketing

I must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials paid for by a third party. However, I may communicate with you over the telehealth platform, by text, by email or face to face about products or services related to your treatment, case management, care coordination, or alternative treatments, therapies, health care providers, or care settings. If you consent to receive such communications, you are welcome to ‘opt-out’ of Remedy marketing, educational and promotional emails or texts at any point in time by notifying Remedy, while staying subscribed to the Remedy care subscription.

I may not sell your PHI without your written authorization.

Uses and Disclosures of Your Highly Confidential Information

Federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including: (1) any portion of your PHI that is kept in psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, treatment and referral; (4) about HIV/AIDS testing, diagnosis or treatment; (5) about sexually transmitted disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) In Vitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.

Your Rights Regarding your Protected Health Information

For Further Information; Complaints

If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our HIPAA Privacy Officer. You may also file written complaints with the Office for Civil Rights (“OCR”) of the U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington D.C. 20201, calling 1-877-796-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. I will not take any action against you if you file a complaint with me or with the OCR.

Right to Receive Confidential Communications

You may ask us to send PHI to a different location than the address that you gave me, or in a special way, or to contact you at a different phone number. You will need to ask me in writing. For example, you may ask me to send a copy of your medical records to a different address than your home address. I will accept all reasonable requests.

Right to Revoke Your Written Permission (Authorization)

You may change your mind about your authorization or any written permission regarding your PHI by giving or sending a written "revocation statement" to the HIPAA Privacy Officer at the address below.

The revocation will not apply to the extent that we have already taken action where I relied on your permission.

Right to Inspect and Copy Your Health Information

You may request copies (for a reasonable fee) and/or access to your medical record file, billing records, and other records. You have a right to a copy of your records if your provider deems that it is in your best interest and would not contribute to worsening of your mental health, if part of a “designated record set” in electronic format, as reasonably available. You can review your medical records and/or ask for hard copies. Under limited circumstances, I may deny you access to a portion of your records. This denial is used if it is determined by your medical team, that reading your medical record may incur further mental health distress. In this case, you may elect to have a summary of your record, or entire record, sent to a new medical treatment team or physician to continue your care with. If you want to access your records, you may obtain a record request form from Dr. Rosenstock and return the completed form to me.

Right to Amend Your Records

You have the right to request that I amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. If you want to amend your records, you may obtain an amendment request form from the HIPAA Privacy Officer. After which, you can return the completed form to the HIPAA Privacy Officer. I will comply with your request unless I believe that the information that would be amended is correct and complete or that other circumstances apply. In the case of a requested amendment concerning information about the Treatment of a mental illness or developmental disability, you have the right to appeal to a state court our decision not to amend your PHI.

Right to Receive an Accounting of Disclosures

You may ask for an accounting of certain disclosures of your PHI made by me. These disclosures must have occurred before the time of your request, and I will not go back more than six (6) years before the date of your request. If you request an accounting more than once during a twelve (12) month period, I will charge you based on the rate sheet. Direct your request for an accounting to the HIPAA Privacy Officer.

Right to Request Restrictions

You have the right to ask me to restrict or limit the PHI I use or disclose about you for treatment, payment, or health care operations. With one exception, I am not required to agree to your request. If I do agree, I will comply unless the information is needed to provide emergency treatment. Your request for restrictions must be made in writing and submitted to the HIPAA Privacy Officer at the address below. I must grant your request to a restriction on disclosure of your PHI to a health plan if you have paid for the health care item in full out of pocket.

Right to Receive a Copy of this Notice

Upon written request, you may obtain a copy of this Notice, even if you have agreed to receive the notice electronically. Please send any such request to the HIPAA Privacy Officer at the address or email address listed below.

Effective Date

This Notice is effective as of July 15, 2020

Right to Change Terms of this Notice

I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all Protected Health Information that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the new notice in common areas throughout our facility, and on our Internet site at www.dramberrosenstock.com. You also may obtain any new notice by contacting the Privacy Officer.

Federal & State Law

Federal and state laws require Dr. Rosenstock to protect your medical information, and federal law requires Dr. Rosenstock to describe to you how I handle that information. When federal and state privacy laws differ, and the state law is more protective of your information or provides you with greater access to your information, then state law will override federal law.

Questions or Concerns: HIPAA Privacy Officer Contact Information

You may contact the Privacy Officer for additional information:

Dr. Amber Rosenstock
Email: dr.amber.rosenstock@gmail.com
Address: 11980 San Vicente Blvd. Suite 711, Los Angeles, CA 90049-9998
Phone: (424)835-1046

I hereby acknowledge that I have been presented with a copy of “Notice of Use of Private Health Information” for the practice of Amber S. Rosenstock, M.D.R., Ph.D. (PSY 22454)