12/21/2024
Country Name: USA
Notice of Privacy Practices
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.
In the course of receiving services from AHF Pharmacies, we will be provided with health information about you. We have a duty under the law to maintain the privacy of this information, and to inform you of our legal obligations. This notice may change from time to time, and we will inform you of any changes. We will abide by this Notice or the most recent Notice. AHF will use this information, and/or disclose it to other people, for the following purposes:
To Provide Medical Treatment To You. We will use this information to provide the very best medical treatment we can. We will consult with doctors, nurses, and other medical professionals when necessary to assure that the right services are being provided to you.
To Assist Others In Providing Medical Services To You. We will disclose this information to other medical professionals who are treating you or helping in your treatment, such as laboratory testers, pharmacists, specialists, etc.
To Obtain And Secure Payment For Our Services. We will disclose this information to people, such as insurance companies, Medi-Cal, Medicare, etc., in order to receive compensation for the services we provide. We may also disclose this information to billing services or other groups that facilitate payment.
To Assess And Improve Our Services. We will use health information in order to evaluate the services we provide, the way we provide them, and the people who provide them. This is done in order to constantly improve the services we provide.
Disclosures Required By Law. Under certain circumstances, state and federal laws require that all holders of health information, not just us, disclose health information to government authorities including courts and public health agencies that monitor health. We will, of course, disclose only that information that is required by law to be disclosed.
Disclosures Benefiting Research. We are engaged in ongoing research into the causes and cures of various medical conditions, and to this end, we operate a Research Department. In order to assist this goal, we may disclose health information to the members of the research department as permitted by state and federal laws, or as approved and directed by a human subject institutional research board (IRB), or as authorized in writing by you. This information will, of course remain confidential within the Research Department.
Psychotherapy Notes. We will not use or disclose your medical information with respect to Psychotherapy Notes
without your written authorization, except for carrying out treatment, payment or health care operations by your mental health practitioner, to use in our own training programs, or to defend ourselves in a legal action by you.
Information About Health Services. We may contact you to remind you about appointments, and to inform you about services, such as pharmacy or other health services that we believe may be beneficial to your health and well-being.
Fund Raising. We are a non-profit corporation, which provides services to people in the United States and abroad, regardless of ability to pay. We may contact you to ask you for support of our non-profit endeavors. You may decline to receive fundraising communications by notifying the AHF Privacy Officer, whose address is 6255 W. Sunset Blvd., 21st Floor, Los Angeles, CA 90028, in writing.
Marketing Activities. We will not use or disclose medical information about you for third-party marketing purposes without your written authorization.
Sale of Medical Information. We will not sell medical information about you without your written authorization.
Electronic Sharing and Pooling of Your Information. We may take part in or make possible the electronic sharing or pooling of your healthcare information. We also participate in national health reform efforts and may use and share information as permitted by law to achieve regional or national goals, including regional or nationally approved population health management or wellness initiatives.
The most common way we do this is through local or regional health information exchanges (HIEs). From time to time, we may also take part in state- or nation-wide internet-based HIEs. As permitted by law, your health information will be shared through the HIE to provide faster access, better coordination of care and to assist us, other healthcare providers, health plans, and public health officials in making more informed decisions.
HIEs help doctors, hospitals and other healthcare providers within any geographic area provide quality care to you. If you travel and need medical treatment, HIEs allow other doctors or hospitals to electronically contact us about you. This helps us manage your care when more than one doctor is involved. It also helps us to keep your health bills lower (by avoiding repeated labs and tests). And finally, it helps us to improve the overall quality of care we provide to you and other patients.
YOUR RIGHTS REGARDING THE INFORMATION ON THE PREVIOUS PAGE:
WE WILL USE OR DISCLOSE ONLY THE MINIMUM NECESSARY HEALTH INFORMATION IN ORDER TO MEET THE PURPOSES AND REQUIREMENTS ON THE PREVIOUS PAGE.
You may request that restrictions be placed on the above uses of medical information, or you may revoke this authorization. However, we do not have to agree to the restriction if we feel that such uses are necessary in order to provide you with the best possible services, unless you request that we restrict your medical information to a health plan as long as (a) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and (b) the medical information pertains solely to a health care item or service for which you have paid us in full.
You have the right to be informed about any breach of unsecured medical information, unless our risk assessment
determines that that there is a low probability that your medical information has been compromised.
You may request that health information be disclosed to you in certain ways, such as a specific mailing address. We will try our best to reasonably accommodate these requests.
You may request to be provided with access to and copies of certain of the health information about you that we maintain.
If you believe that health information is inaccurate or incomplete, you may request that the medical information be amended.
If you wish to obtain a current list of the HIEs that we participate in or if you want to opt-out of participating in HIEs, please contact either your AHF provider or the Privacy Officer.
You may ask for a record of the disclosures made by us of your health information.
You may ask for a copy of this Notice.
If you have any questions or complaints about this Notice or about your health information, please call our Privacy Officer at 323-860-5200. You may also contact the Secretary of the United States Department of Health and Human Services. You will not be retaliated against in any way for asking questions or making a complaint.
The effective date of this Notice is , and lasts for as long as you are a client of AHF.
ACCEPTANCE: I certify that I have read, understand, and agree to the terms of this Notice, and authorize the release of the above information
Dated: By:
Print Name
If client declines to sign, Staff sign here: