patient registration form peds - (7-12-11 rev) … patient registration form section 1 - if you have...

Pediatric Patient Registration Form Section 1 - If you have more than one child and their registration information is the same, please skip to Section 2.

Our staff will copy and return the form to you to complete Section 1 - (one form for each child). Patient (Legal) Last Name First Name (Legal) Preferred Name Full Middle Name

Date of Birth Gender Social Security Number Primary Care Physician Religious Affiliation

/ / Female __ Male __ - -

Preferred Spoken Language Preferred Written Language Need an Interpreter?

Yes or No

Ethnicity (circle one) Race (circle one)

Hispanic or Latino / Non Hispanic or Latino or Unknown

Asian / Black African-American / Caucasian / Hawaiian-Pacific Islander Native American-Eskimo / Multi-Racial-Other / Decline to State - Unknown

Section 2 - Please complete this section and the back page.

Patient Address (Number, Street, Apt #) City State Zip Code

Bill To Address (if same as above, leave blank)

Mailing Address (Number, Street, Apt #) City State Zip Code

Parent or Legal Guardian Information

Parent/Legal Guardian of Minor Date Of Birth Relationship to Minor

/ /

Phone 1 (Home, Cell, Work/Other) ( ) - Would you like an appointment reminder call? Yes or No

Phone 2 (Home, Cell, Work/Other) ( ) - Phone 3 (Home, Cell, Work/Other) ( ) -

Email Address @ .com or .net or ._____ (circle one)

Parent/Legal Guardian of Minor Date of Birth Relationship to Minor

/ /

Phone 1 (Home, Cell, Work/Other) ( ) - Phone 2 (Home, Cell, Work/Other) ( ) -

Emergency Contact

Emergency Contact’s Name Relationship to patient Phone

( ) -

Insurance Holder Information

Insurance Holder Name (Subscriber) Date of Birth Relationship to Patient Phone Number

/ / ( ) -

/ / ( ) -

Insurance Holder Employer Information

Employer Name & Address (Number, Street, Apt #, City, State, Zip Code) Employer Phone Number

( ) -

( ) -

Do you have a copy of your insurance card with you today? Yes ___ No ___ (If no, please complete this section)

Health Plan Information Primary Health Plan Secondary Health Plan

Health Plan Name

Health Plan Address

Phone Number ( ) - ( ) -

Subscriber Number

Signature ___________________________ Relationship to Patient ________________________ Date _______________

Form # 3197001B, 3/1/13 See Reverse Side

JMPN: Communication Preference Form | Rev. 02.27.13

Confidential Communication Preference Date: ______________________ Patient Name: ___________________________________ Date of Birth: ___________________________ Parent/Legal Guardian Name for Minor Patients: ______________________________________________ Our current Notice of Privacy Practices allows us to call you with a courtesy reminder regarding upcoming appointments. In some cases it may become necessary to contact you by telephone to discuss other medical information. In the event that you are unavailable, we would like to be able to leave you a detailed message (e.g., lab results, x-rays, and other test results).

Please read the following choices and tell us whether or not we can leave a detailed message (e.g., lab results, x-rays, and other test results) on an answering machine and/or with any specific individuals you designate below.

Choose one of the following:

□I consent and authorize to John Muir Physician Network and their staff to leave a telephone detailed message

regarding my medical care or my minor child at the following numbers (initial each phone number provided).

□ Home answering machine: Initials:

□ Cell Phone: Initials:

□ Work/Other Phone: Initials:

□I consent and authorize John Muir Physician Network to disclose verbally any results or instructions to the following

specified person(s) who are at least 18 years or older and may answer the above phone number(s) in my absence: Designated Person Name: Relationship:

Designated Person Name:

Relationship:

□I do not consent or authorize detailed messages regarding my medical care to be left on my answering machine or

with a designated person. I wish to be contacted personally. I understand that there may be delays in receiving my results.

This communication preference will remain in effect until you rescind or provide a change.

Signature______________________________________________________ Date __________________________ Internal Use Only:

Revised 1/21/13

Patient Name ____________________________________ Date of Birth ____________ (Last, First, Middle)

ACKNOWLEDGEMENT RECEIPT OF NOTICE OF PRIVACY PRACTICES (NOPP)

The undersigned acknowledges he/she has received a copy of the Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information (PHI). You may also obtain a copy on our web-site at www.johnmuirhealth.com or contacting our customer service department at (925) 952-2887.

_________________________________ __________________________ Patient/Legal Representative Signature Date

Staff Use Only (check box): NOPP Offered Pt Declined to Sign Emergency Situation NOPP Not Offered

_______________________________________________________________________________________ ASSIGNMENTS OF BENEFITS

Financial Waiver/Policy I hereby assign medical and/or surgical payments to include major medical benefits to which I am entitled, private insurance and any other health plan to John Muir Physician Network for services provided by John Muir Medical Group.

By signing this document (below), I understand if claims are denied due to eligibility status, invalid medical group or invalid Primary Care Physician (PCP), I will assume full responsibility for all charges incurred by me and all dependents. Additionally, I will be held financially responsible for any non-covered benefits, deductibles or any co-payments for services, which have been provided to me. We always recommend that you check with your health plan prior to receiving any medical services to assess your benefits and eligibility for coverage. We typically submit our office specimens to John Muir Laboratories unless specifically requested at the time of service of every visit. It is my responsibility to understand my insurance benefits and plan coverage. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

OTHER FINANCIAL POLICIES

Release of Information for Reimbursement

To the extent necessary to obtain reimbursement, the physician’s office may disclose any portion of the patient’s record, including his/her medical records, to any party the patient has identified as liable for any portion of the physicians charges, including but not limited to, insurance companies, healthcare service plans, workers’ compensation carriers, social security administration and peer review organizations. You agree, in order for us to service your account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Late / Cancellations / Appointment No Shows If you cancel your appointment with less than 8 business hours (8 business hours – 1 business day), or miss your appointment, you will be charged a fee. It is within the physician’s discretion to dismiss you from the practice if you’ve had repeated cancellations or no-show appointments.

Charges for Completion of Forms and Photo Copying Medical Records: There is a charge for completion of forms and photo copying of medical records.

Payment Method: For your convenience, we accept VISA, MasterCard, Discover Card, and cash. Personal checks will only be accepted for insurance co-payments. Please make your check payable to John Muir Physician Network. There may be a charge for returned checks. By signing this document, I understand and agree with the Assignments of Benefits and Other Financial Policies listed above.

_________________________________ __________________________ Patient /Legal Representative Signature Date

http://www.johnmuirhealth.com/

T his notice summarizes how your medicalinformation may be used and disclosed andhow you may obtain access to the

information. See the attached full Notice of PrivacyPractices for complete details.

The John Muir Physician Network, and oura�liated physicians and other healthcareprofessionals, who treat you, are committed toprotecting your medical information.

We are required by law to:

• Make sure that medical information thatidenti�es you is kept private, except as youauthorize or as laws require or permit.

• Give you a Notice of Privacy Practice thatdescribes our legal duties and privacypractices with respect to your medicalinformation.

• Follow the terms of the Notice of PrivacyPractice that is currently in e�ect.

We may use and disclose your medical informationfor treatment, payment and our healthcareoperations. We may share your information withother professional individuals/agencies that areinvolved in your care at our medical o�ces, urgentcare centers, x-ray/ mammography, weight loss or

PRIVACY PRACTICES SUMMARY Page 1PHI-12 (9/14/09)

osteoporosis centers or other Health Networko�ces. We may disclose your medical informationto our clinical research sta� in order to determine ifyou may be a candidate for a clinical study. We maydisclose your information as required by law, suchas for public health activities to prevent or controldisease, to report abuse situations, to notify peopleof recall of products, or in response to a courtorder.

You have a right to inspect and copy your medicalinformation (i.e. medical and billing records). Youmay request to amend your records if you feel theinformation is incorrect or incomplete. To requestan amendment, you must submit a written requestand must provide a reason to support the request.You have a right to an accounting of certaindisclosures of your information that we have madeand a right to request restrictions of our use ordisclosure of your medical information. For moreinformation on these rights, see the full Notice ofPrivacy Practices attached.

If you believe your privacy rights have beenviolated, you may �le a complaint with us or withthe Secretary of the Department of Health andHuman Services. Complete contact information isprovided in our full Notice of Privacy Practices.

E�ective Date: 8/1/05

N OTICE OF PRIVACY PRACTICESSUMMARY

with the Secretary of the Department of Health andHuman Services. To �le a complaint with the listedentities, contact the following persons at the respectiveentity where care was rendered. All complaints mustbe submitted in writing. You will not be penalized for�ling a complaint.

• Privacy O�cial at the Practice you are seen at.• John Muir Physician Network-

Quality Improvement925-941-2028

• John Muir Physician Network, Entity PrivacyO�cial at 925-952-2820

• Secretary of Department of Health andHuman Services:

Director, O�ce for Civil RightsU.S. Department of Health andHuman Services200 Independence Avenue,SW–Room 506-FWashington, D.C. 20201(202) 619-0403Director, O�ce for Civil RightsU.S. Department of Health andHuman Services50 United Nations Plaza–Room 322San Francisco, CA 94103(415) 437-8310

OTHER USES OF MEDICALINFORMATION__________________________________

Other uses and disclosures of medical information notcovered by this Notice of Privacy Practices or the lawsthat apply to us will be made only with your writtenpermission. If you provide us permission to use ordisclose your medical information, you may revokethat permission, in writing, at any time. If you revokeyour permission, we will no longer use or disclosemedical information about you for the reasonscovered by your written authorization, except if wehave already acted in reliance on your permissions.You understand that we are unable to take back anydisclosures we have already made with yourpermission, and that we are required to retain ourrecords of the care that we provided to you.

in writing to one of the designated authorities. Inyour request, you must tell us (1) whatinformation you want to limit; (2) whether youwant to limit our use, disclosure or both; and (3)to whom you want the limits to apply, for example,disclosures to your spouse.

Right to Request Con�dentialCommunicationsYou have the right to request that we communicatewith you about medical matters in a certain way orat a certain location. For example, you can ask thatwe only contact you at work or by mail.

To request con�dential communications, you mustmake your request in writing at the time ofadmission or registration, or to the Medical Recordsdepartment of the medical o�ce where your servicesare or were provided. We will not ask you the reasonfor your request. We will accommodate allreasonable requests. Your request must specify howor where you wish to be contacted.

Right to a Paper Copy of This Notice ofPrivacy PracticesYou have the right to a paper copy of this Notice ofPrivacy Practices. You may also access this Notice ofPrivacy Practices at our web-site,www.johnmuirmtdiablo.com.

CHANGES TO THIS NOTICE__________________________________

We reserve the right to change this Notice of PrivacyPractices. We reserve the right to make the revised orchanged Notice of Privacy Practices e�ective foryour medical information we already have aboutyou as well as any information we receive in thefuture. We will post a copy of the current Notice ofPrivacy Practices with the current date in the listedentities.

COMPLAINTS__________________________________

If you believe your privacy rights have been violated,you may �le a complaint with the listed entities or

Page 8 PRIVACY PRACTICES SUMMARY PHI-12 (9/14/09)

If you have any questions about this Notice ofPrivacy Practices, please contact the Privacy Officialas listed below:John Muir Physician Network – PrivacyOfficial at your physicians’ office

John Muir Physician Network –Quality Improvement, 925-944-2028

John Muir Physician Network- ChiefOperating Officer, 925-952-2820

John Muir Health corporate offices and departments –VP, Compliance (Privacy Official), 925-947-3344

WHO WILL FOLLOW THIS NOTICEOF PRIVACY PRACTICES__________________________________

This Notice describes the John Muir PhysicianNetwork and that of:

• Any health care professional authorized toaccess and/or enter information into themedical charts that we maintain. Thisincludes all physicians and other healthcareprofessionals who are members of ouraffiliated medical staff.

• All departments and units of the John MuirPhysician Network listed below.

• All employees, staff and other personnel ofthese units.

• All volunteers, trainees, or students.

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATIONABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TOTHIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: 4/29/08

NOTICE OF PRIVACY PRACTICES

Page 2 PRIVACY PRACTICES SUMMARY

John Muir Physician NetworkUnitsThis Notice of Privacy Practices applies to theHealth Network’s corporate departments involvedin healthcare, and some departments of John MuirHealth Corporation that assist us with ouroperations, such as but not limited to:Community Health Alliance (Mobile HealthClinic), Patient Accounting, Information TechnologyServices, Financial Services, and Marketing.

John Muir Physician Network physician practices(as of 4/29/08) listed below:

Walnut Creek106 La Casa Via, Suites 100 & 2061455 Montego, Suites 103,104 & 2052255 Ygnacio Valley Rd, Suites A & N2121 Ygnacio Valley Rd, #106 Bldg. E1220 Rossmoor Parkway

Osteo Center1656 N. California Street, Suite 200

Pleasant Hill380 Civic Drive, Suite 100401 Gregory Lane #10491 Gregory Lane #15

Concord2700 Grant St, Suite 2005161 Clayton Rd, #F

Antioch3440 Hillcrest Ave, Suite 150

Brentwood2400 Balfour Rd, Suite 120 & 229

Lafayette3466 Mt. Diablo Boulevard, Suite C-104

We may deny your request to inspect and copy incertain very limited circumstances. If you are deniedaccess to your medical information, youmay request that the denial be reviewed. Yourrequest and denial will be reviewed by the followingdepartment at the involved entity:

• The Director of Quality Improvement atJohn Muir Physician Network or the EntityPrivacy Official for John Muir PhysicianNetwork.

The person conducting the review will not be theperson who initially denied your request. We willcomply with the outcome of the review.

Right to AmendIf you feel that the medical information we haveabout you is incorrect or incomplete, you may askus to amend the information.

A request for an amendment must be made inwriting to the Medical Records Department whereyour services were provided. In addition, you mustprovide a reason to support the requestedamendment.

We may deny your request for an amendment if itis not in writing or does not include a reason tosupport the request. Additionally, we may denyyour request if you ask us to amend informationthat:

• Was not created by us;• Is not part of the medical information kept

by the Health Network;• Is not part of the information which you

would be permitted to inspect and copy; or• Is accurate and complete.

If your request for amendment is denied, you havethe right to submit a written addendum, not toexceed 250 words, with respect to any item orstatement in your record you believe is incompleteor incorrect. If you clearly indicate in writing thatyou want the addendum to be made part of yourmedical record, we will attach to it your records andinclude it whenever me make a disclosure of the

PRIVACY PRACTICES SUMMARY Page 7

item or statement you believe to be incomplete orincorrect.

Right to an Accounting of DisclosuresYou have the right to request a list of names/agenciesto whom we may have given your medicalinformation. This list will not include ourown uses for Treatment, Payment and Health CareOperations, or for other reasons specified by laws.

To request this list of disclosures, you must submityour request in writing to the Privacy Official whereyour services were provided. Your request must statea time period, which may not be longer than sixyears and may not include dates before April 14,2003. The first list you request within a 12-monthperiod will be free. For additional lists, we maycharge you for the costs of providing the list. We willnotify you of the cost involved and you may chooseto withdraw or modify your request at that timebefore any costs are incurred.

Right to Request RestrictionsYou have the right to request a restriction orlimitation on your medical information we use ordisclose about you for Treatment, Payment orHealth Care Operations. You also have the right torequest a limit on the medical information wedisclose about you to someone (like a familymember or friend) who is involved in your care orthe payment for your care. For instance, you mayrequest us not to use or disclose medicalinformation concerning a procedure you had.Authorities designated to review your request are:Practice Privacy Official, Entity Privacy Official,Health System Privacy Official.

We are not required to agree to your requestIf we do agree, we will comply with your requestunless the information is needed to provide youemergency treatment. If we do not agree, we willnotify you of the reason we cannot comply withyour request.

To request restrictions, you must make your request

Orinda140 Brookwood Road, Suite 201

Alamo1505 St. Alphonsus Way

Danville907 San Ramon Valley Blvd., Suite 202

San Ramon / Bishop Ranch2305 Camino Ramon Suites 100, and 120

Pleasanton5720 Stoneridge Mall Road, Suite 330

John Muir Physician Network extendedservices, such as but not limited to: TheOsteoporosis Center, Metabolic Nutrition Program,Center for Nutrition and Weight Management, andEast Bay Clinical Trial Center.

All these entities, sites and locations will followthe terms of this Notice of Privacy Practices. Inaddition, these entities, sites and locations mayshare medical information with each other forTreatment, Payment or Health Care Operationspurposes described in this Notice of PrivacyPractices.Additional entities, which are covered by theirown Notice of Privacy Practices: John MuirMedical Center, Walnut Creek and departments,John Muir Medical Center, Concord anddepartments, John Muir Behavioral Health Center,Aspen Surgery Center, Diablo Valley Surgery Center,John Muir Magnetic Imaging Center, and Neuroscan.

Please note that the above entities will have theirown Notice of Privacy Practices for care that theyprovide to you while you are in their facilities.

PLEDGE REGARDING MEDICALINFORMATION__________________________________

We are committed to protecting medicalinformation about you. In order to provide youwith quality care and to comply with certain legalrequirements, we create a record of the care andservices you receive. This Notice of Privacy Practicesapplies to all of the records of your care that are usedto make medical decisions about you.

This Notice of Privacy Practices tells you or yourlegal representative about the ways in which wemay use and disclose your medical information.We also describe your rights and certain obligationsregarding the use and disclosure of medicalinformation.


• make sure that medical information thatidentifies you is kept private, except as youauthorize or as required or permitted by law;

• give you this Notice of Privacy Practices ofour legal duties and privacy practices withrespect to medical information about you;and

• follow the terms of the Notice of PrivacyPractices that is currently in effect.

HOW WE MAY USE AND DISCLOSEYOUR MEDICAL INFORMATION__________________________________

The following categories describe different waysthat we may use and disclose your medicalinformation. For each category of uses or disclosureswe will explain what we mean and try to give someexamples. Not every use or disclosure in a categorywill be listed. However, all of the ways we arepermitted to use and disclose information will fallwithin one of the categories.

TreatmentWe may use your medical information to provideyou with medical treatment or services. We maydisclose your medical information to physicians,nurses, technicians, medical students, and staff intraining or other personnel who are involved in yourcare. For example, a physician treating you for abroken leg may need to know if you have diabetesbecause diabetes may slow the healing process. It maybe necessary to disclose your information in order toarrange for lab work, prescriptions, x-rays1or other medical tests. We also may disclose medicalinformation about you to people outside of thepractice you visit to entities within the Health


accrediting, and licensing. These activities arenecessary for the government to monitor the healthcare system, government programs, and compliancewith civil and patient rights laws.

Lawsuits and DisputesIf you are involved in a lawsuit or a dispute, we maydisclose your medical information in response to acourt or administrative order. We may also discloseyour medical information in response to a subpoena,discovery request, or other lawful process. Inaccordance with California Law, efforts may bemade to tell you about the request or to obtain anorder protecting the information requested.

Law EnforcementWe may release your medical information if asked todo so by a law enforcement official:

• In response to a court order, subpoena,warrant, summons or similar process;

• To identify or locate a suspect, fugitive,material witness, or missing person;

• About the victim of a crime if, under certainlimited circumstances, we are unable toobtain the victim’s agreement;

• About a death we believe may be the resultof criminal conduct;

• About criminal conduct at the listed entities;and in emergency circumstances to report acrime; the location of the crime or victims;or the identity, description or location of theperson who committed the crime.

Coroners, Medical Examiners and FuneralDirectorsWe may release your medical information to acoroner, medical examiner or funeral director. Thismay be necessary to identify a deceased person ordetermine the cause of death, or to enable suchpersons to carry out their duties.

National Security and Intelligence ActivitiesWe may release your medical information to

PRIVACY PRACTICES SUMMARY

authorized federal officials for intelligence,counterintelligence, and other national securityactivities authorized by law.

Protective Services for the President of theUnited States and othersWe may disclose your medical information toauthorized federal officials so they may provideprotection to the President, other authorized personsor foreign heads of state or to conduct specialinvestigations.

InmatesIf you are an inmate of a correctional institution orunder the custody of a law enforcement official, wemay release your medical information to thecorrectional institution or law enforcement official.This release would be necessary (1) for theinstitution to provide you with health care; (2) toprotect your health and safety or the health andsafety of others; or (3) for the safety and security ofthe correctional institution.

YOUR RIGHTS REGARDING YOURMEDICAL INFORMATION__________________________________

You have the following rights regarding medicalinformation we maintain about you:

Right to Inspect and CopyYou have the right to inspect and copy medicalinformation that may be used to make decisionsabout your care. Usually, this includes medical andbilling records, but may not include some mentalhealth information.

To inspect and copy your medical information thatmay be used to make decisions about you, you mustsubmit your request in writing to the MedicalPractice Office where your services were provided.

If you request a copy of the information, we maycharge a fee for the costs of copying, mailing or othersupplies associated with your request.

Network or John Muir Health. We may disclosemedical information to affiliated entities who maybe involved in your medical care while you arehospitalized, and who may provide care after youreturn home, such as placement agencies, homehealth agencies, nursing homes, or others as orderedby your physician for continuity of care purposes.

PaymentWe may use and disclose your medical informationso that the treatment and services you receive may bebilled and payment may be collected from aninsurance company, a third party, or from you. Forexample, we may be required to provide your healthplan information regarding the office visit youreceived so that your health plan will compensate orreimburse you or us for the visit. We may alsoinform your health plan concerning a treatment youare going to receive to obtain prior approval or todetermine whether your plan will cover thetreatment. Other examples of disclosures would beto laboratories, pharmacies or Durable MedicalEquipment Companies for their billing purposes.

Health Care OperationsWe may use and disclose your medical informationfor Health Care Operations. These uses anddisclosures are necessary to operate the HealthNetwork and John Muir Health and to ensure thatall of our patients receive quality care. For example,we may utilize your medical information to reviewour treatment and services and to evaluate theperformance of our staff in caring for you. We mayalso combine medical information of many patientsto decide what additional programs and services weshould offer and whether certain new treatmentsare effective. We may remove information thatidentifies you from these sets of medicalinformation so others may use them to studyhealth care and health care delivery withoutlearning who the specific patients are. We may alsodisclose information to physicians, nurses,technicians, medical students, nursing students,students in other healthcare fields, and otherpersonnel for review and learning purposes.

Appointment RemindersWe may use and disclose medical information tocontact your household to provide a reminder thatyou have an appointment for treatment or medicalcare at the listed entities.

Treatment AlternativesWe may use and disclose medical information to tellyou about or recommend possible treatment optionsor alternatives that may be of interest to you.

Health-Related Programs and ServicesWe may use and disclose medical information to tellyou about the many health-related programs orservices we offer that may be of interest to you.These communications are sent with the intent toinform you about our wide scope of services and arenot meant to represent any form of inducement orencouragement to use our services.

Fundraising ActivitiesWe may use your demographic information (nameand address) and dates of treatment for the purpose ofraising funds for the Health Network or John MuirHealth. We may disclose limited medical informationto a foundation related to the Health System so thefoundation may contact you regarding raising moneyfor John Muir Health. If your demographicinformation is used, contact information and anopportunity to decline further mailings will beprovided by following a straightforward process torequest removal from our list.

Individuals Involved in Your Care orPayment for Your CareWe may release your medical information to a friendor family member or legal representative who isinvolved in your medical care. We may also giveinformation to someone who helps pay for yourcare. In addition, we may disclose your medicalinformation to an entity assisting in a disaster reliefeffort so that your family can be notified about yourcondition, status and location.


ResearchUnder certain circumstances, we may use anddisclose your medical information for researchpurposes. East Bay Clinical Trial Center, a part ofthe John Muir Physician Network, conducts clinicalstudies. The clinicians of Muir/Diablo Primary CareMedical Group serve as researchers in connectionwith certain trials. The Health Network’sparticipation in the advancement of science andmedicine may be of benefit to you.However, in order to provide you with the usefulinformation concerning the availability to you ofthese treatments, we may review your medicalrecord periodically to determine whether you maybe eligible to participate in certain clinical studies.These studies may include the use of aninvestigational drug or medical device. They mayalso be used to validate the use of an existing drugor medical device for a new medical indication. Incertain circumstances, we believe it is consistentwith your treatment to consider these kinds ofoptions in connection with your care. Only theclinicians or study coordinators from East BayClinical Trial Center will review your medicalrecord during these reviews and none of yourprotected health information will be disclosed tothird parties without your specific authorization. Ifit is preliminarily determined that you may beeligible for such treatment and that such treatmentmight be beneficial to you, your physician or amember of East Bay Clinical staff will contact youwith further information.

As Required By LawWe may disclose your medical information whenrequired to do so by federal, state or local law.

To Avert a Serious Threat to Health orSafetyWe may use and disclose your medical informationwhen necessary to prevent a serious threat to yourhealth and safety or the health and safety of thepublic or another person. Any disclosure, however,would only be to someone able to help prevent thethreat.

SPECIAL SITUATIONS__________________________________

Military and VeteransIf you are a member of the armed forces, we mayrelease your medical information as required bymilitary command authorities. We may also releasemedical information about foreign militarypersonnel to the appropriate foreign militaryauthority.

Workers’ CompensationWe may release your medical information forworkers’ compensation or similar programs. Theseprograms provide benefits for work-related injuriesor illness.

Public Health RisksWe may disclose your medical information forpublic health activities. These activities generallyinclude the following:

• To prevent or control disease, injury ordisability;

• To report births and deaths;• To report the abuse or neglect of children,

elders and dependent adults;• To report reactions to medications or

problems with products;• To notify people of recalls of products they

may be using;• To notify a person who may have been

exposed to a disease or may be at risk forcontracting or spreading a disease orcondition;

• To notify the appropriate governmentauthority or reporting agency if we believe apatient has been the victim of abuse, neglector domestic violence; but only whenrequired or authorized by law.

Health Oversight ActivitiesWe may disclose your medical information to ahealth oversight agency for activities authorized bylaw. These oversight activities include, for example,governmental audits, investigations, inspections, and


Orinda140 Brookwood Road, Suite 201

Alamo1505 St. Alphonsus Way

Danville907 San Ramon Valley Blvd., Suite 202

San Ramon / Bishop Ranch2305 Camino Ramon Suites 100, and 120

Pleasanton5720 Stoneridge Mall Road, Suite 330

John Muir Physician Network extendedservices, such as but not limited to: TheOsteoporosis Center, Metabolic Nutrition Program,Center for Nutrition and Weight Management, andEast Bay Clinical Trial Center.

All these entities, sites and locations will followthe terms of this Notice of Privacy Practices. Inaddition, these entities, sites and locations mayshare medical information with each other forTreatment, Payment or Health Care Operationspurposes described in this Notice of PrivacyPractices.Additional entities, which are covered by theirown Notice of Privacy Practices: John MuirMedical Center, Walnut Creek and departments,John Muir Medical Center, Concord anddepartments, John Muir Behavioral Health Center,Aspen Surgery Center, Diablo Valley Surgery Center,John Muir Magnetic Imaging Center, and Neuroscan.

Please note that the above entities will have theirown Notice of Privacy Practices for care that theyprovide to you while you are in their facilities.

PLEDGE REGARDING MEDICALINFORMATION__________________________________

We are committed to protecting medicalinformation about you. In order to provide youwith quality care and to comply with certain legalrequirements, we create a record of the care andservices you receive. This Notice of Privacy Practicesapplies to all of the records of your care that are usedto make medical decisions about you.

This Notice of Privacy Practices tells you or yourlegal representative about the ways in which wemay use and disclose your medical information.We also describe your rights and certain obligationsregarding the use and disclosure of medicalinformation.


• make sure that medical information thatidentifies you is kept private, except as youauthorize or as required or permitted by law;

• give you this Notice of Privacy Practices ofour legal duties and privacy practices withrespect to medical information about you;and

• follow the terms of the Notice of PrivacyPractices that is currently in effect.

HOW WE MAY USE AND DISCLOSEYOUR MEDICAL INFORMATION__________________________________

The following categories describe different waysthat we may use and disclose your medicalinformation. For each category of uses or disclosureswe will explain what we mean and try to give someexamples. Not every use or disclosure in a categorywill be listed. However, all of the ways we arepermitted to use and disclose information will fallwithin one of the categories.

TreatmentWe may use your medical information to provideyou with medical treatment or services. We maydisclose your medical information to physicians,nurses, technicians, medical students, and staff intraining or other personnel who are involved in yourcare. For example, a physician treating you for abroken leg may need to know if you have diabetesbecause diabetes may slow the healing process. It maybe necessary to disclose your information in order toarrange for lab work, prescriptions, x-rays1or other medical tests. We also may disclose medicalinformation about you to people outside of thepractice you visit to entities within the Health


accrediting, and licensing. These activities arenecessary for the government to monitor the healthcare system, government programs, and compliancewith civil and patient rights laws.

Lawsuits and DisputesIf you are involved in a lawsuit or a dispute, we maydisclose your medical information in response to acourt or administrative order. We may also discloseyour medical information in response to a subpoena,discovery request, or other lawful process. Inaccordance with California Law, efforts may bemade to tell you about the request or to obtain anorder protecting the information requested.

Law EnforcementWe may release your medical information if asked todo so by a law enforcement official:

• In response to a court order, subpoena,warrant, summons or similar process;

• To identify or locate a suspect, fugitive,material witness, or missing person;

• About the victim of a crime if, under certainlimited circumstances, we are unable toobtain the victim’s agreement;

• About a death we believe may be the resultof criminal conduct;

• About criminal conduct at the listed entities;and in emergency circumstances to report acrime; the location of the crime or victims;or the identity, description or location of theperson who committed the crime.

Coroners, Medical Examiners and FuneralDirectorsWe may release your medical information to acoroner, medical examiner or funeral director. Thismay be necessary to identify a deceased person ordetermine the cause of death, or to enable suchpersons to carry out their duties.

National Security and Intelligence ActivitiesWe may release your medical information to


authorized federal officials for intelligence,counterintelligence, and other national securityactivities authorized by law.

Protective Services for the President of theUnited States and othersWe may disclose your medical information toauthorized federal officials so they may provideprotection to the President, other authorized personsor foreign heads of state or to conduct specialinvestigations.

InmatesIf you are an inmate of a correctional institution orunder the custody of a law enforcement official, wemay release your medical information to thecorrectional institution or law enforcement official.This release would be necessary (1) for theinstitution to provide you with health care; (2) toprotect your health and safety or the health andsafety of others; or (3) for the safety and security ofthe correctional institution.

YOUR RIGHTS REGARDING YOURMEDICAL INFORMATION__________________________________

You have the following rights regarding medicalinformation we maintain about you:

Right to Inspect and CopyYou have the right to inspect and copy medicalinformation that may be used to make decisionsabout your care. Usually, this includes medical andbilling records, but may not include some mentalhealth information.

To inspect and copy your medical information thatmay be used to make decisions about you, you mustsubmit your request in writing to the MedicalPractice Office where your services were provided.

If you request a copy of the information, we maycharge a fee for the costs of copying, mailing or othersupplies associated with your request.

If you have any questions about this Notice ofPrivacy Practices, please contact the Privacy Officialas listed below:John Muir Physician Network – PrivacyOfficial at your physicians’ office

John Muir Physician Network –Quality Improvement, 925-944-2028

John Muir Physician Network- ChiefOperating Officer, 925-952-2820

John Muir Health corporate offices and departments –VP, Compliance (Privacy Official), 925-947-3344

WHO WILL FOLLOW THIS NOTICEOF PRIVACY PRACTICES__________________________________

This Notice describes the John Muir PhysicianNetwork and that of:

• Any health care professional authorized toaccess and/or enter information into themedical charts that we maintain. Thisincludes all physicians and other healthcareprofessionals who are members of ouraffiliated medical staff.

• All departments and units of the John MuirPhysician Network listed below.

• All employees, staff and other personnel ofthese units.

• All volunteers, trainees, or students.

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATIONABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TOTHIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: 4/29/08

NOTICE OF PRIVACY PRACTICES


John Muir Physician NetworkUnitsThis Notice of Privacy Practices applies to theHealth Network’s corporate departments involvedin healthcare, and some departments of John MuirHealth Corporation that assist us with ouroperations, such as but not limited to:Community Health Alliance (Mobile HealthClinic), Patient Accounting, Information TechnologyServices, Financial Services, and Marketing.

John Muir Physician Network physician practices(as of 4/29/08) listed below:

Walnut Creek106 La Casa Via, Suites 100 & 2061455 Montego, Suites 103,104 & 2052255 Ygnacio Valley Rd, Suites A & N2121 Ygnacio Valley Rd, #106 Bldg. E1220 Rossmoor Parkway

Osteo Center1656 N. California Street, Suite 200

Pleasant Hill380 Civic Drive, Suite 100401 Gregory Lane #10491 Gregory Lane #15

Concord2700 Grant St, Suite 2005161 Clayton Rd, #F

Antioch3440 Hillcrest Ave, Suite 150

Brentwood2400 Balfour Rd, Suite 120 & 229

Lafayette3466 Mt. Diablo Boulevard, Suite C-104

We may deny your request to inspect and copy incertain very limited circumstances. If you are deniedaccess to your medical information, youmay request that the denial be reviewed. Yourrequest and denial will be reviewed by the followingdepartment at the involved entity:

• The Director of Quality Improvement atJohn Muir Physician Network or the EntityPrivacy Official for John Muir PhysicianNetwork.

The person conducting the review will not be theperson who initially denied your request. We willcomply with the outcome of the review.

Right to AmendIf you feel that the medical information we haveabout you is incorrect or incomplete, you may askus to amend the information.

A request for an amendment must be made inwriting to the Medical Records Department whereyour services were provided. In addition, you mustprovide a reason to support the requestedamendment.

We may deny your request for an amendment if itis not in writing or does not include a reason tosupport the request. Additionally, we may denyyour request if you ask us to amend informationthat:

• Was not created by us;• Is not part of the medical information kept

by the Health Network;• Is not part of the information which you

would be permitted to inspect and copy; or• Is accurate and complete.

If your request for amendment is denied, you havethe right to submit a written addendum, not toexceed 250 words, with respect to any item orstatement in your record you believe is incompleteor incorrect. If you clearly indicate in writing thatyou want the addendum to be made part of yourmedical record, we will attach to it your records andinclude it whenever me make a disclosure of the


item or statement you believe to be incomplete orincorrect.

Right to an Accounting of DisclosuresYou have the right to request a list of names/agenciesto whom we may have given your medicalinformation. This list will not include ourown uses for Treatment, Payment and Health CareOperations, or for other reasons specified by laws.

To request this list of disclosures, you must submityour request in writing to the Privacy Official whereyour services were provided. Your request must statea time period, which may not be longer than sixyears and may not include dates before April 14,2003. The first list you request within a 12-monthperiod will be free. For additional lists, we maycharge you for the costs of providing the list. We willnotify you of the cost involved and you may chooseto withdraw or modify your request at that timebefore any costs are incurred.

Right to Request RestrictionsYou have the right to request a restriction orlimitation on your medical information we use ordisclose about you for Treatment, Payment orHealth Care Operations. You also have the right torequest a limit on the medical information wedisclose about you to someone (like a familymember or friend) who is involved in your care orthe payment for your care. For instance, you mayrequest us not to use or disclose medicalinformation concerning a procedure you had.Authorities designated to review your request are:Practice Privacy Official, Entity Privacy Official,Health System Privacy Official.

We are not required to agree to your requestIf we do agree, we will comply with your requestunless the information is needed to provide youemergency treatment. If we do not agree, we willnotify you of the reason we cannot comply withyour request.

To request restrictions, you must make your request

T his notice summarizes how your medicalinformation may be used and disclosed andhow you may obtain access to the

information. See the attached full Notice of PrivacyPractices for complete details.

The John Muir Physician Network, and oura�liated physicians and other healthcareprofessionals, who treat you, are committed toprotecting your medical information.


• Make sure that medical information thatidenti�es you is kept private, except as youauthorize or as laws require or permit.

• Give you a Notice of Privacy Practice thatdescribes our legal duties and privacypractices with respect to your medicalinformation.

• Follow the terms of the Notice of PrivacyPractice that is currently in e�ect.

We may use and disclose your medical informationfor treatment, payment and our healthcareoperations. We may share your information withother professional individuals/agencies that areinvolved in your care at our medical o�ces, urgentcare centers, x-ray/ mammography, weight loss or

PRIVACY PRACTICES SUMMARY Page 1PHI-12 (9/14/09)

osteoporosis centers or other Health Networko�ces. We may disclose your medical informationto our clinical research sta� in order to determine ifyou may be a candidate for a clinical study. We maydisclose your information as required by law, suchas for public health activities to prevent or controldisease, to report abuse situations, to notify peopleof recall of products, or in response to a courtorder.

You have a right to inspect and copy your medicalinformation (i.e. medical and billing records). Youmay request to amend your records if you feel theinformation is incorrect or incomplete. To requestan amendment, you must submit a written requestand must provide a reason to support the request.You have a right to an accounting of certaindisclosures of your information that we have madeand a right to request restrictions of our use ordisclosure of your medical information. For moreinformation on these rights, see the full Notice ofPrivacy Practices attached.

If you believe your privacy rights have beenviolated, you may �le a complaint with us or withthe Secretary of the Department of Health andHuman Services. Complete contact information isprovided in our full Notice of Privacy Practices.

E�ective Date: 8/1/05

N OTICE OF PRIVACY PRACTICESSUMMARY

with the Secretary of the Department of Health andHuman Services. To �le a complaint with the listedentities, contact the following persons at the respectiveentity where care was rendered. All complaints mustbe submitted in writing. You will not be penalized for�ling a complaint.

• Privacy O�cial at the Practice you are seen at.• John Muir Physician Network-

Quality Improvement925-941-2028

• John Muir Physician Network, Entity PrivacyO�cial at 925-952-2820

• Secretary of Department of Health andHuman Services:

Director, O�ce for Civil RightsU.S. Department of Health andHuman Services200 Independence Avenue,SW–Room 506-FWashington, D.C. 20201(202) 619-0403Director, O�ce for Civil RightsU.S. Department of Health andHuman Services50 United Nations Plaza–Room 322San Francisco, CA 94103(415) 437-8310

OTHER USES OF MEDICALINFORMATION__________________________________

Other uses and disclosures of medical information notcovered by this Notice of Privacy Practices or the lawsthat apply to us will be made only with your writtenpermission. If you provide us permission to use ordisclose your medical information, you may revokethat permission, in writing, at any time. If you revokeyour permission, we will no longer use or disclosemedical information about you for the reasonscovered by your written authorization, except if wehave already acted in reliance on your permissions.You understand that we are unable to take back anydisclosures we have already made with yourpermission, and that we are required to retain ourrecords of the care that we provided to you.

in writing to one of the designated authorities. Inyour request, you must tell us (1) whatinformation you want to limit; (2) whether youwant to limit our use, disclosure or both; and (3)to whom you want the limits to apply, for example,disclosures to your spouse.

Right to Request Con�dentialCommunicationsYou have the right to request that we communicatewith you about medical matters in a certain way orat a certain location. For example, you can ask thatwe only contact you at work or by mail.

To request con�dential communications, you mustmake your request in writing at the time ofadmission or registration, or to the Medical Recordsdepartment of the medical o�ce where your servicesare or were provided. We will not ask you the reasonfor your request. We will accommodate allreasonable requests. Your request must specify howor where you wish to be contacted.

Right to a Paper Copy of This Notice ofPrivacy PracticesYou have the right to a paper copy of this Notice ofPrivacy Practices. You may also access this Notice ofPrivacy Practices at our web-site,www.johnmuirmtdiablo.com.

CHANGES TO THIS NOTICE__________________________________

We reserve the right to change this Notice of PrivacyPractices. We reserve the right to make the revised orchanged Notice of Privacy Practices e�ective foryour medical information we already have aboutyou as well as any information we receive in thefuture. We will post a copy of the current Notice ofPrivacy Practices with the current date in the listedentities.

COMPLAINTS__________________________________

If you believe your privacy rights have been violated,you may �le a complaint with the listed entities or

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