Notice of Privacy Practices

6620 Coyle Avenue, Suite 202, Carmichael, CA 95608
Ph: 916-966-8500; Fax: 916-966-8555
3270 Arena Boulevard, Suite 405, Sacramento, CA 95834
Ph: 916-418-4595; Fax: 916-418-4594
Email: hello@ample.health

Effective Date: May 21, 2025

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.

Our Commitment to Your Privacy- At AmpleHealth, we are committed to protecting the privacy of your protected health information (PHI). PHI is information about you, including demographic details, that may identify you and relates to your past, present, or future physical or mental health or condition, the provision of healthcare services, or payment for those services. This Notice of Privacy Practices explains how we may use and disclose your PHI, your rights regarding your PHI, and our obligations under federal and California state law, including the Health Insurance Portability and Accountability Act (HIPAA) and the California Confidentiality of Medical Information Act (CMIA).

How We May Use and Disclose Your Protected Health Information (PHI)- We may use or disclose your PHI for the following purposes, as permitted or required by law:

1. For Treatment: We may use your PHI to provide you with medical treatment or services. For example, we may share your PHI with doctors, nurses, or other healthcare providers involved in your care, such as specialists or laboratories, to coordinate your treatment.
2. For Payment: We may use and disclose your PHI to bill and collect payment for the services we provide. For example, we may send your PHI to your health insurance company to receive payment for a visit or procedure.
3. For Healthcare Operations: We may use and disclose your PHI to support the business operations of our practice. For example, we may use your PHI to evaluate the quality of care, train staff, or conduct internal audits.
4. Appointments and Services: We may use your PHI to contact you about appointment reminders, treatment options, or other health-related services that may be of interest to you.
5. Individuals Involved in Your Care: We may disclose your PHI to a family member, friend, or other person you designate as involved in your care or payment for your care, unless you object. In emergencies or if you are incapacitated, we may disclose your PHI if we believe it is in your best interest, based on our professional judgment.
6. Business Associates: We may share your PHI with third-party business associates who perform services on our behalf, such as billing or electronic health record vendors, provided they agree to safeguard your PHI under a written agreement.

7. As Required by Law: We will disclose your PHI when required by federal, state, or local law, such as reporting communicable diseases or responding to a court order.
8. Public Health and Safety: We may disclose your PHI to prevent or lessen a serious threat to your health or safety or that of others, or for public health activities, such as reporting abuse, neglect, or certain injuries.
9. Health Oversight Activities: We may disclose your PHI to health oversight agencies for activities like audits, investigations, or licensure actions.
10. Legal Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, or other lawful process, subject to applicable legal requirements.
11. Research: We may use or disclose your PHI for research purposes, but only with your authorization or if the research is approved by an institutional review board that ensures your privacy is protected.
12. Deceased Patients: We may disclose PHI of a deceased patient to coroners, medical examiners, or funeral directors as necessary, or to family members unless the patient previously objected.

Uses and Disclosures Requiring Your Authorization- Other uses and disclosures of your PHI not covered by this notice or applicable law will be made only with your written authorization. For example:
● Marketing: We will not use your PHI for marketing purposes without your authorization, except for face-to-face communications or promotional gifts of nominal value.
● Sale of PHI: We will not sell your PHI without your authorization.
● Psychotherapy Notes: We will not use or disclose psychotherapy notes without your authorization, except as permitted by law.
● Highly Confidential Information: Under California law, certain sensitive information, such as HIV test results or mental health records, may require your specific authorization for disclosure.

You may revoke your authorization in writing at any time, except to the extent that we have already acted on it.

Your Rights Regarding Your Protected Health Information- Under federal and California law, you have the following rights regarding your PHI:

1. Right to Inspect and Copy: You have the right to inspect and obtain a copy of your PHI in our designated record set, such as medical or billing records, for as long as we maintain it. You must submit a written request, and we may charge a reasonable fee for copying, mailing, or other supplies. In certain cases, we may deny access, but you may request a review of that denial.
2. Right to Amend: If you believe your PHI is incorrect or incomplete, you may request that we amend it. You must submit a written request with a reason for the amendment. We may deny your request in certain cases, such as if the information is accurate or was created by another provider.
3. Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures of your PHI made by us in the past six years, excluding disclosures for treatment, payment, healthcare operations, or those you authorized. Your first request in a 12-month period is free; additional requests may incur a fee.
4. Right to Request Restrictions: You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations, or to certain individuals involved in your care. We are not required to agree to your request, except when you pay out-of-pocket in full for a service and request that we not disclose that PHI to your health plan for payment or operations purposes.
5. Right to Confidential Communications: You have the right to request that we communicate with you in a specific way or at a specific location (e.g., only by phone or at a different address). We will accommodate reasonable requests.
6. Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice at any time, even if you agreed to receive it electronically.
7. Right to Breach Notification: You have the right to be notified if there is a breach of your unsecured PHI, as required by law.

Our Responsibilities- We are required by law to:
● Maintain the privacy and security of your PHI.
● Provide you with this notice of our legal duties and privacy practices.
● Abide by the terms of the notice currently in effect.
● Notify you if there is a breach of your unsecured PHI.

We reserve the right to change our privacy practices and the terms of this notice at any time, as permitted by law. Changes will apply to all PHI we maintain. If we make significant changes, we will post the revised notice in our office, on our website (if applicable), and provide a copy upon request.

Safeguards for Telemedicine Services- If you receive telemedicine services from our practice, we will encrypt your PHI during electronic transmission and store it securely, either by us or a selected service provider. We will not disseminate personally identifiable images or information from telemedicine sessions to researchers or other healthcare providers, except as required by federal or California law. You are responsible for using secure devices and networks for telemedicine communications, as using public or shared computers may increase privacy risks.

Complaints- If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. To file a complaint with us, contact: AmpleHealth, Dheeraj Kamra, MD 6620 Coyle Avenue, Suite 302, Carmichael, CA 95608. Ph: 916-966-8500 Fax: 916-966-8555 Email: hello@ample.health

To file a complaint with the Office for Civil Rights, contact: U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 Phone: (800) 368-1019 TDD: (800) 537-7697 Website: https://www.hhs.gov/ocr

You will not be penalized or retaliated against for filing a complaint.

Contact Us- For questions about this notice or our privacy practices, please contact: AmpleHealth, Dheeraj Kamra, MD 6620 Coyle Avenue, Suite 302, Carmichael, CA 95608. Ph: 916-966-8500 Fax: 916-966-8555 Email: hello@ample.health

Acknowledgement

By signing below, I acknowledge that I have received a copy of this Notice of Privacy Practices.