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Notice of Privacy Practice





                                                                                          Effective Date: APRIL 14, 2003


This notice describes how your medical information about you may be used and disclosed and how you can get access to this information. 

Please review it carefully.

If you have any questions about this notice, please contact CATHERINE RELLS


Operation Samahan Inc. is a community health center serving you and your family. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

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 the notice that is currently in effect.



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 the categories.

 For Treatment. We will use and disclose your protected health information to our physicians, nurses, and others involved in your health care or preventative care.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.  We may disclose information to other health care professionals to coordinate or manage your health care.

 For Payment. Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan or a state program paying for your health care services may undertake before it approves or pays for the services we recommend for you such as; making a determination of eligibility or coverage of benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan or an appropriate state program to obtain approval for a referral to a specialist or for hospital admission.

 For Health Care Operations. We may use or disclose, your protected health information in order to provide quality care and support the business activities of our practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising, and conducting or arranging for other business activities.

For example, we may disclose your protected health information to medical school students and other trainees that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you.

We may also disclose your protected health information to organizations that participate with us in an integrated care delivery system for such activities as: quality assessment and improvement activities; activities designed to improve health and reduce the cost of health care; protocol development, case management and care coordination; integrated care.  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.

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.


Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment.

 Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

 Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

 Fundraising Activities. We may use medical information about you to contact you in an effort to raise money for the health center and its operations. We may disclose medical information to a foundation related to the health center so that the foundation may contact you in raising money for the clinic. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at the clinic.  If you do not want the clinic to contact you for fundraising please notify our Privacy Contact, CATHERINE RELLS, in writing and request that these fundraising materials not be sent to you.

 Individuals Involved in Your Care or Payment for Your Care. Under certain circumstances, we may disclose medical information about you to family members, other relatives, or close personal friends or others that you identify.  The information we disclose will be limited to information directly relevant to their involvement with your care or payment related to your care; or to notify them of your location, general condition, or death.

Many patients ask us to disclose medical information to people in ways not described above. For example, an elderly person may want us to make her records available to a neighbor who is helping her resolve a question about her care or payment for that care.  A patient may request that a family member be allowed to pick up a prescription or documents for them.  You will be asked to provide Contact information to authorize us to disclose your personal health information to a person or organization when you are not present.  If you fill out a form and later change your mind, you may send a letter to us at the address listed on the form to let us know that you would like to revoke the special authorization. In any communication with us, please provide your name, address, patient or member identification number or Social Security number, and a telephone number where we can reach you in case we need to contact you about your request.

 Research.  We may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health of patients who received one set of services to those who received another, for the same condition.  All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the health center.

 As Required By Law. We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the 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 disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

 Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

 Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

  • to prevent or control disease, injury or disability;
  • to report births and deaths;
  • to report the abuse or neglect of children, elders and dependent adults;
  • to report reactions to medications or problems with products;
  • to notify people of recalls of products they may be using;
  • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.


Health Oversight Activities. We may disclose medical information to a health oversight agency such as: [your organizations health oversight agencies], for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.


Legal Proceedings.  We may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

 Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death we believe may be the result of criminal conduct;
  • About criminal conduct at the health center; and
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.

Military Activity and National Security. When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities.

 Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Required Uses and Disclosures.  Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Other Uses and Disclosures.  Uses and disclosures not covered by this notice or the laws that apply to us will be made only with your written and signed authorization.  If you authorize us to use or disclose your protected health information you may revoke that authorization, in writing, at any time.  If you revoke the authorization we will no longer use or disclose your protected health information for the reasons covered by the authorization.  You understand that we are unable to take back any disclosures we have already made with your authorization.


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

 Right to Inspect and Copy. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.  Usually, this includes medical and billing records, but does not include some psychotherapy notes.

To inspect and copy your protected health information you must submit your request in writing to CATHERINE RELLS. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

The protected health information of minors, who are authorized by law to act as an individual in requesting medical services, may only be inspected or copied by the minor individual without written authorization or other legal authority.

We may deny your request to inspect and copy your protected health information in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the health center will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

 Right to Amend. If you feel that medical information we have about you in a designated record set 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 the health center. To request an amendment, your request must be made in writing and submitted to CATHERINE RELLS. In addition, you must provide a reason that supports 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 you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer
  • available to make the amendment;
  • Is not part of the medical information kept by or for the health center;
  • Is not part of the information which you would be permitted to inspect and copy; or
  • Is accurate and complete.


If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

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 other than our own uses for treatment, payment and health care operations, as those functions are described above.  It excludes disclosures we may have made to you, or were authorized by you, to family members or friends involved in your care, or for notification purposes.

To request this list or accounting of disclosures, you must submit your request in writing to CATHERINE RELLS. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, 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 Request Restrictions. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.


Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.

To request restrictions, you must make your request in writing to CATHERINE RELLS. 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 at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request.

To request confidential communications, you must make your request in writing to CATHERINE RELLS.

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. You may obtain a copy of this notice at our website, To obtain a paper copy of this notice, you can call our main clinic at (619) 477-4451.


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. We will post a copy of the current notice in the health center. The notice will contain on the first page, in the top right-hand corner, the effective date. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. Or you may obtain a copy at our website,


If you believe your privacy rights have been violated, you may complain to us or to the Secretary of Health and Human Services. You may file a complaint with us by notifying CATHERINE RELLS at (619) 477-4451.  All complaints must be submitted in writing.  We will not retaliate against you for filing a complaint.