Privacy Statement





We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

As permitted by law, we reserve the right to amend or modify our privacy policies and practices.

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 we maintain.

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy health information be submitted in writing. You may obtain a form to request access to your records by contacting our privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.


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 or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan and from other sources such as 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 service 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 our Company. 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.


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.


Appointment reminders: Your health information may be used by our staff to send you appointment reminders.

Information About Treatments: Your health information may be used to send you information that you may find interesting about the treatment and management of your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.

Fundraising: Unless you request us not to, we may use your name and address to support our fund-raising efforts, if any. If you do not want to participate in fund-raising efforts, please mark the appropriate box on your disclosure form.


If you would like to submit a comment or complaint about our privacy practices, or would like to request a copy of any of the information mentioned in this notice, you can do so by sending a letter to:

Sylvia Parrett, R.N., Privacy Officer

27882 Forbes Road, Suite 200

Laguna Niguel, CA 92677

Phone (949) 249- 9200

If you believe that your privacy rights have been violated, you should call 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

The name and address of the person you can contact for further information concerning our privacy practices is as noted above. You may call:

Sylvia Parrett R.N., Privacy Officer at: (949) 249-9200

Effective Date

This Notice is effective on or after September 4, 2014

The Medical Board of California

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815


Toll-Free 1-800-633-2322


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