Coastal Radiation Oncology Medical Group

All patients seen are asked to sign this Notice. Please bring this form to your initial consultation appointment at a Coastal Center.

Coastal Radiation Oncology Medical Group, Inc. is committed to maintaining the privacy of our patients. As such, and in accordance with the Health Insurance Portability and Accountability Act (HIPAA), we have developed Coastal's Notice of Privacy Practices. This Notice states how our medical practice will use your personally identifiable health information and your rights regarding the use of this information.

THIS NOTICE DESCRIBES HOW OUR MEDICAL PRACTICE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. IT ALSO DESCRIBES YOUR RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OUR LEGAL OBLIGATIONS WITH RESPECT TO YOUR MEDICAL INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRIVACY OFFICER LISTED ABOVE. We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We have implemented procedures and instructed our staff to protect the privacy of your medical records at all times. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. This Notice of Privacy Practices extends to any Coastal Radiation Oncology Medical Group, Inc. office in which you may receive treatment.

By law, we may share your health information for treatment, payment and health care operations. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly.

Treatment. We may share your medical information with your referring or consulting physicians or other health care providers who provide you care or treatment.

Payment. To obtain authorization or payment for the services we provide, we may share your information with your health plan.

Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, for business management or for legal services and audits, including fraud and abuse detection and compliance programs. We will also follow State and Government reporting requirements. For example, we will disclose this information to the California Tumor Tissue Registry. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will use and disclose your health information. We will limit our use or disclosure to the relevant requirements of the law. We may also share your medical information with our business associates that perform administrative services for us and have agreed to protect your privacy.

Appointment Reminders. We may contact you to remind you about appointments. We may leave this information on your answering machine or in a message left with the person answering the phone.

Sign in sheet. We may ask you to sign in when you arrive at our office. We may also call out your name when we are ready to see you.

Notification and communication with family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location and your general condition. In case of a disaster, we may disclose information to a relief organization. If you are able and available, we will give you the opportunity to agree or object to the disclosure. Otherwise, our health professionals will use their best judgment in communication with your family and others.

Marketing. We may give you information or recommendations about products or services related to your treatment or to provide you with small gifts. We will not use or disclose your medical information for marketing purposes without your written authorization.

Research. We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.

When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

Your Health Information Rights include the:

Right to Request Special Privacy Protections. You may request, in writing, restrictions on certain uses and disclosures of your health information. We may accept or reject your request, and will notify you of our decision.

Right to Request Alternative Confidential Communications. You may request that you receive your health information in a specific way. For example, you may ask that we send information to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. You must submit a written request detailing what medical information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee, as allowed by California law. We may deny your request under limited circumstances.

Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. Your request must be in writing, and include the reasons you believe the information is inaccurate or incomplete. If your request is denied, we will provide you with information about the denial and how you can disagree with the denial. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect.

Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice. This accounting will not include disclosures for treatment, payment or healthcare operations, disclosures provided to you or authorized by you, communication with family or specialized government functions. Certain legal activities may restrict these rights.

You have a right to receive a paper copy of this Notice of Privacy Practices.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Office Supervisor or our Privacy Officer listed at the top of this Notice of Privacy Practices.

Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will post the current notice in our reception area and this page of our website.

Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices. You will not be penalized for filing a complaint. If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

Acknowledgment of Receipt of Notice of Privacy Practices

Coastal Radiation Oncology Medical Group, Inc.
316 South Stratford Avenue, Suite C, Santa Maria, CA 93454
Privacy Officer - Thomas D. Fogel, M.D.
Phone #: (805) 648-5191

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

Signed: ___________________________ Date: ____________________ Print Name: _______________________ Telephone: __________________

If signed by other than the patient, please indicate Relationship:

  parent or guardian of minor patient

  guardian or conservator of an incompetent patient

   beneficiary or personal representative of deceased patient

Name of Patient: _________________________________________

If not signed by patient or other, please indicate reason not obtained: ____________________________________________________________

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For Office Use Only:

 

Date received:                                                               Processed by: