HIPAA
Bellagance, Inc. notice of Privacy Practices
Effective January, 1 2024
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.
WHO WILL FOLLOW THIS NOTICE?
This notice describes the practices of Bellagance, Inc. and the practices
that will be followed by all of Bellagance, Inc. workforce members who
handle your medical information.
OUR PLEDGE REGARDING YOUR PROTECTED HEALTH INFORMATION
Bellagance, Inc. understands that medical information about you and your
health is personal. We are committed to protecting medical information
about you. We maintain our records and conduct our treatment environment
with a goal of providing the highest level of protection for your medical
information, while still providing you with the highest level of medical
care. This notices applies to all of the records of your medical care
which are received or created by Bellagance, Inc..
Your other medical treatment providers (e.g. doctors, hospitals, home
health agencies, etc.) may have different policies or notices regarding
the use and disclosure of your medical information.
This notice will tell you about the ways in which Bellagance, Inc. may use
and disclose medical information about you. Your medical information, also
referred to as “protected health information” is that information about
you, including demographic information, that may identify you and that
relates to your past, present or future physical or mental health
information and related health care services.
In this notice, we also describe your rights and certain obligations
Bellagance, Inc. has regarding the use and disclosure of your protected
health information. We are required by name to:
Make sure that medical and other information that identifies you
(protected health information) is kept private.
Give your this notice of our legal duties and privacy practices with
respect to protected health information about you.
Follow the terms of the notice that is currently in effect.
USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
By becoming a patient at Bellagance, Inc., you are giving consent for
Bellagance, Inc. to use your protected health information for certain
activities, including treatment, payment and other health care operations.
Sometimes, you may hear these three activities referred to as “TPO”.
First of all, we may use and disclose protected health information about
you so that Bellagance, Inc. and its medical professionals can treat you.
For example, we may use your past medical information in order to diagnose
your present condition or we may provide information regarding your
medical condition to another doctor to whom we refer you for additional
care. We may also use and disclose protected health information about you
so that we may be paid for the medical treatment we provide you. For
example, we will submit protected health information about you to your
insurance company in order to receive payment for services we have
provided to you. We may also use and disclose protected health information
about you for Bellagance, Inc.‘s health care operations, in other words,
those other tasks that we need to perform to make sure that you are
provided the highest quality of medical care. For example, we may use your
protected health information to evaluate how we can better meet your needs
or we may provide protected health information about you to an auditor who
reviews our books so that we can keep our license to provide medical
services in.
OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
The following uses of your protected health information may be made
without any additional authorization from you. (Not every use or
disclosure is listed, but be assured that all uses and disclosures made by
Bellagance, Inc. are only those which are permitted under the law).
USES AND DISCLOSURES FOR APPOINTMENT REMINDERS
We may use and disclose your medical information to contact you as a
reminder that you have an appointment at the office. If you request that
such communications be made confidentially, please contact our office in
writing at 201 S. Lasky Drive, Beverly Hills, CA 90212. We will
accommodate all reasonable requests.
USES AND DISCLOSURES TO OTHERS INVOLVED IN YOUR HEALTHCARE
We may disclose to a member of your family, a relative, a close friend, or
any other person you identify, your protected health information that
directly relates to that person’s involvement in your medical care. If you
are unable to agree or object to this disclosure, we may disclose such
information as necessary if we determine that it is in your best interests
based on our professional judgment. We may also use or disclose protected
health information to notify or assist in notifying a family member,
personal representative or any other person that is responsible for your
care of your location, general condition, or death. Finally, we may use or
disclose your protected health information to an authorized public or
private entity to assist in disaster relief efforts and to coordinate uses
and disclosures to family or other individuals involved in your health
care.
USES AND DISCLOSURES IN EMERGENCY SITUATIONS
We may use or disclose your protected health information in an emergency
treatment situation. If this happens, your physician will attempt to
obtain your acknowledgment of this Notice as soon as reasonably
practicable after the delivery of treatment.
USES AND DISCLOSURES FOR HEALTH-RELATED BENEFITS OR SERVICES
From time to time, Bellagance, Inc. may use and disclosure protected
health information to tell you about certain health related benefits or
services that may be of interest to you.
USES AND DISCLOSURES REQUIRED BY LAW
We will use or disclose protected health information about you when
required to do so by federal, state, or local law. The use or disclosure
will be made in compliance with the law and will be limited to the
relevant requirements of the law. You will be notified, if the law
requires us to do so, of any such uses or disclosures. We must make
disclosures to you and when required by the Secretary of the Department of
Health and Human Services to investigate or determine our compliance with
the law.
USES AND DISCLOSURES RELATED TO COMMUNICABLE DISEASES
We may disclose your protected health information, if authorized by law,
to a person who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading the disease or condition.
DISCLOSURES FOR HEALTH OVERSIGHT ACTIVITIES
We may disclose protected health information to a health oversight agency
for activities authorized by law. These activities include, for example,
audits, investigations, and inspections. These activities are necessary
for the government to monitor the health care system, the delivery of
health care, government benefit programs, other government regulatory
programs and civil rights laws.
DISCLOSURES OF ABUSE OR NEGLECT
We may disclose your protected health information to a public health
authority authorized by law to receive reports of child abuse or neglect.
In addition, we may disclose your protected health information if we
believe that you have been a victim of abuse, neglect or domestic violence
to a governmental entity or agency authorized to receive such information.
In such cases, the disclosure will only be made in accordance with law.
DISCLOSURES TO THE FOOD AND DRUG ADMINISTRATION
We may disclose your protected health information to a person or company
required by the Food and Drug Administration (FDA) to report adverse
events, product defects or other problems, biologic product deviations,
track products; to enable product recalls; to make repairs or
replacements; or to conduct post-market surveillance, as required.
DISCLOSURES FOR LAWSUITS AND DISPUTES
If you are involved in a lawsuit or a dispute, we may disclose protected
health information about you in response to a court order or
administrative order. We may also disclose protected health information
about you in response to a subpoena, discovery request, or other lawful
process by someone else involved in the dispute, but only if efforts have
been made to tell you about the request or to obtain an order protecting
the information requested.
DISCLOSURES TO LAW ENFORCEMENT
We may release protected health information if asked to do so by a law
enforcement official, in response to a court order, subpoena, warrant,
summons, or similar process.
Other related disclosures may include disclosures relating to individuals
who are Armed Forces personnel, to national security and intelligence
agencies, as well as disclosures to authorized federal officials for the
protection of the President of the United States or other authorized
persons or foreign heads of state.
DISCLOSURES TO CORONERS, FUNERAL DIRECTORS, AND ORGAN DONATION
We may disclose protected health information about you to a coroner or
medical examiner for identification purposes, determining cause of death,
or for the coroner or medical examiner to perform other duties required by
law. We may also disclose protected health information about you to a
funeral director in order to permit the funeral director to carry out
legal duties, and may do so if death is reasonably anticipated. Your
protected health information may also be disclosed for certain organ
donations to which you may have agreed.
DISCLOSURES FOR RESEARCH
We may disclose your protected health information to researchers when
their research has been approved and protocols have been established to
ensure the privacy of your information. We may also disclose a limited set
of your information, as allowed under the law, for research purposes.
DISCLOSURES RELATED TO CRIMINAL ACTIVITY
We may disclose your protected health information, consistent with federal
and laws, if we believe that the use or disclosure is necessary to prevent
or lessen a serious or imminent threat to the health or safety of a person
or the public, or if it is necessary for law enforcement authorities to
identify or apprehend an individual.
DISCLOSURES FOR WORKERS’ COMPENSATION
We may release protected health information about you for Workers’
Compensation or similar programs. These programs provide benefits for
work-related injuries or illnesses.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
RIGHT TO INSPECT AND COPY
You have the right to inspect and copy protected health information that
may be used to make decisions about your medical care. Usually this right
includes both medical and billing records. You must submit your request in
writing. If you request a copy of the information, we may charge a fee for
the costs of copying, mailing or other supplies associated with your
request. Your request to inspect and copy your information may only be
denied in very limited circumstances and you have a right to request that
any such denial be reviewed.
RIGHT TO REQUEST RESTRICTIONS
You have the right to request that we restrict the use and disclosure of
your protected health information for treatment, payment and health care
operations. We are not required to agree to your request. If we do agree,
we will comply with your request unless the information is needed to
provide you emergency treatment.
To request restrictions, you must make your request in writing to 201 S.
Lasky Drive, Beverly Hills, CA 90212. In your request, you must tell us:
What information you want to limit.
Whether you want to limit our use, disclosure, or both.
To whom you want the limits to apply.
RIGHT TO CONFIDENTIAL COMMUNICATIONS
You also have the right to request to receive private health information
communications (such as appointment confirmations) by alternative means or
at alternative locations. For example, you can ask that we only contact
you at work or by mail. To request confidential communications, you must
make your request in writing to 201 S. Lasky Drive, Beverly Hills, CA
90212. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or
where you wish to be contacted.
RIGHT TO AMEND
If you feel that the protected health information we have about you is
incorrect or incomplete, you have the right to request that your protected
health information be amended. Only the health care entity (e.g., doctor,
hospital, clinic, etc.) that created your protected health information is
responsible for amending it. For more information regarding the procedures
for submitting such a request, contact 201 S. Lasky Drive, Beverly Hills,
CA 90212.
RIGHT TO AN ACCOUNTING OF DISCLOSURES
You have a right to an accounting of disclosures of your protected health
information, for purposes other than treatment, payment or health care
operations by Bellagance, Inc. or any of the people or companies who
perform treatment, payment or health care operations on our behalf. To
request this list of disclosures we made of protected health information
about you, you must submit a request in writing to 201 S. Lasky Drive,
Beverly Hills, CA 90212. Your request must state a time period which may
not be longer than six (6) years prior to the date of your request and may
not include dates before August 1, 2005. Your request should indicate the
form in which you want the list (for example, on paper or electronically).
You will be charged for photocopying.
RIGHT TO A PAPER COPY OF THIS NOTICE
You have the right to a paper copy of this Notice. You may ask us to give
you a copy of this notice at any time.
You may obtain a copy of this Notice at our website: bellagance.com
To obtain a paper copy of this Notice, contact 310-424-4000
To learn more about these procedures, or to make any of these requests,
you should contact our Office Manager at 310-424-4000.
CHANGES TO THIS NOTICE
Bellagance, Inc. reserves the right to change this notice. We reserve the
right to make the revised or changed Notice effective for protected health
information we already have about you, as well as any information we
create or receive in the future. We will post a copy of the current Notice
on Bellagance, Inc. website: bellagance.com. The Notice will contain, in
the top right-hand corner, the effective date.
COMPLAINTS
If you believe your privacy rights have been violated and/or that
Bellagance, Inc. has not followed this policy, you may file a complaint
with the Office Manager at Bellagance, Inc. or with the Secretary of the
Department of Health and Human Services.
To file a complaint with Bellagance, Inc., contact Office Manager, 201 S.
Lasky Drive, Beverly Hills, CA 90212. All complaints must be submitted in
writing. You will not be penalized for filing a complaint.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of your protected health information not
covered by this notice or the laws that apply to Bellagance, Inc. will be
made only with your written permission (“authorization”). If you provide
us permission to use or disclose protected health information about you,
you may revoke that permission, in writing, at any time. If you revoke
your permission, we will no longer use or disclose protected health
information about you for the reasons covered by your authorization. You
understand that we are unable to take back any disclosures we have already
made with your permission, and that we are required to retain our records
of the medical treatment or other services that we have provided to you.
QUESTIONS?
If you have any questions regarding this notice, please contact the Office
Manager at Bellagance, Inc..