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:
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.
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.
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.
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
If client declines to sign, Staff sign here: