HIPAA: Notice of Privacy Practices
Effective April 14, 2003

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

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.

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

Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Bayside Medical Group, Inc. For example, information on the services you received may be used to support budgeting and financial reporting and activities to evaluate and promote quality.

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.

Appointment reminders. Your health information will be used by our staff to remind you of future appointments.

Information about treatments. Your health information may be used to send you information the treatment and management of your medical condition. We may also send you information describing other health-related products and services.

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

Individual Rights

You have certain rights under the federal privacy standards. These include:

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 amend 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; and

the right to receive a printed copy of this notice.

Bayside Medical Group, Inc.'s Duties

It is our duty to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We must also abide by the privacy policies and practices outlined in this notice.

Right to Revise Privacy Practices

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 within our practice.

Requests to Inspect Protected Health Information

As permitted by federal regulation, your request to inspect or copy your protected health information must be submitted in writing. You may obtain a form to request access to your records by contacting the Office Manager or the Privacy Officer. Your request will be reviewed and will usually be approved unless there are legal or medical reasons to deny the request.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

Privacy Officer
Bayside Medical Group, Inc.
11875 Dublin Blvd., Suite B-125
Dublin, CA 94568

If you believe your privacy rights have been violated, you should bring 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

To contact us for further information regarding our privacy practices, please address your correspondence to:

Privacy Officer
Bayside Medical Group, Inc.
11875 Dublin Blvd., Suite B-125
Dublin, CA 94568

Effective date

This notice is effective as of Monday, April 14, 2003.