Notice of Privacy Policy Summary

To our patients: This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information:

Use and disclosure of your health information in certain special circumstances

The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information.

2 Lawsuits and similar proceedings in response to a court or administrative order.

3) If required to do so by a law enforcement official.

4) When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.

5) If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

6) To federal officials for intelligence and national security activities authorized by law.

7) To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.

8) For Workers Compensation and similar programs.

Your rights regarding your health information:

1) You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2)You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3)You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to StrykerMD, A Professional Medical Corporation, 153 S. Sierra Avenue Suite 990, Solana Beach, CA 92075.

Note: We must respond to this request within 30 days.

4) You may ask us to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to StrykerMD, A Professional Medical Corporation, 153 S. Sierra Avenue Suite 990, Solana Beach, CA 92075. You must provide us with a reason that supports your request for amendment.

Note: We must respond within 60 days. The Privacy Officer or the patient’s physician will usually do this. If the physician believes the information is complete and accurate, the physician can refuse to make any changes.

5)Your health information will not be used for marketing or fundraising purposes unless authorized by you to do so. Additionally, we will not sell patient health care information to 3rd parties unless instructed to do so by you.

6)Should we begin utilizing electronic medical records, you have the right to receive them in an electronic form.

7)We will obtain written authorization from you should we wish to utilize information in your health records for research purposes.

8)We must obtain your permission to disclose immunization records to schools or other requesting parties.

9)You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist.

10)If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Carla Valdez at StrykerMD. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

11)Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Carla at StrykerMD.

This document is to be signed by a person legally responsible for the patient’s medical decisions relative to the treatment situation.

I understand that if I have questions or complaints I may contact:

I also understand that I am entitled to receive updates upon request if StrykerMD amends or changes its Notice of Privacy Practices in a material way. Privacy Practices Policy effective July 1, 2004.