Logo - Urgent Care Center Med Stop Madonna Plaza SLO


Effective date: 4/14/2003
As required by the Privacy Regulations Created as a result of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).



Our practice is dedicated to maintaining the privacy of your personal health information (herein referred to as PHI).  We will create records regarding you and the treatment and services we provide to you and may receive such records from others.  We use these records to provide or enable other health provides to provide quality medical care, to obtain payment for services provided to you and to enable us to meet our professional and legal obligations to operate our practice.  We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and the privacy practices concerning your PHI.  This notice also describes your rights and our legal obligations with respect to your medical information.

This document is intended to provide you with information regarding the following topics:

  • How we may use and disclose your PHI
  • Your privacy rights
  • Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all our records containing your PHI that are created or retained by our practice.  We reserve the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future.


Lara Cathcart, Privacy Officer
283 Madonna Road, Suite B
San Luis Obispo, CA 93405
(805) 549-8880

This practice collects health information about you and it is stored in a chart.  This is your medical record.  The medical record is the property of this practice, but information belongs to you.  The law permits us to use or disclose your PHI for the following purposes:
1.   Treatment.  Our practice may use your PHI to treat you.  We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your PHI with other healthcare providers who will provide services to you that we do not provide.   We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription or to a laboratory that performs a test.   Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents.
2.  Payment.  We may use and disclose your PHI in order to obtain payment for the services and items you may receive from us.  For example, we give your health plan the PHI it requires before it will pay us.  We may also disclose PHI to other providers to assist them in obtaining payment for the services they have provided you.
3.  Health Care Operations.  Our practice may use and disclose your PHI to operate our business.  For example, our practice may use PHI to evaluate the quality of care you receive from us, or to conduct cost-management and business planning activities for our practice.  Or we may use or disclose PHI to get your health plan to authorize services or referrals.  We may also use or disclose PHI as necessary for medical reviews, legal services and audits.  We may also share your PHI with our “business associates” such as our billing service that perform administrative services for us.  We have a written contract with our business associates that require these associates to agree to protect your PHI. We may also share your information via multiple applications and other electronic means of communication, both secure and unsecure, with hospitals, other physicians and their staff for the purpose of communicating results and gathering input on your diagnostic examinations so we may improve your diagnostic and treatment options.
4.  Appointment Reminders.  Our practice may use and disclose your PHI to contact you and remind you of an appointment.  If you are not home, we may leave this information on your answering machine or with the person answering the phone.
5.  Sign-in Sheet.  We may use and disclose PHI by having you sign in when you arrive and we may also call out your name when we are ready to see you.
6.  Notification of Test Results.  Our practice may use and disclose your PHI to notify you of test results via phone or mail contact.
7.  Release of Information to Family/Friends.  Our practice may release your PHI to a designated friend or family member that is involved in your care, or who helps pay for your care.
8.  Treatment Options/Health Related Benefits.  Our practice may use and disclose your PHI to inform you of potential treatment options and/or health related benefits or services that may be of interest to you.
9.  Disclosures Required by Law.  Our office will use and disclose your PHI when we are required to do so by federal, state or local law, but we will limit our use or disclosure to the relevant requirements of the law.  When the law requires us to report abuse, neglect or domestic violence, or to respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth concerning those activities.
10.  Public Health. We may, and are sometime required by law to disclose your PHI to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent abuse and neglect or domestic violence; reporting reactions to drugs or problems with products or devices; reporting disease or infection exposure.
11. Special Circumstances.  We may use or disclose your PHI under the following special circumstances: notifying a person regarding potential risk for spreading or contracting a disease or condition; notifying individuals if a product or device they may be using is recalled; maintaining vital records, such as births and deaths; notifying your employer under limited circumstances related primarily to workplace injury or medical surveillance.
12. Health Oversight Activities.  We may, and are sometime required by law to disclose your PHI to a health oversight agency during the course of investigations, inspections, inspections, audits, licensure and other proceedings subject to the limitation imposed by federal and California law.
13. Lawsuits and Similar Proceedings.  Our practice may, and is sometimes required by law, to disclose your PHI in response to a court or administrative order or other judicial proceeding to the extent expressly authorized by a court or administrative order.  We may also disclose PHI in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you and you have not objected, or if your objections have been resolved by a court or administrative order.
14. Law Enforcement. We may, and are sometime required by law to disclose your PHI to a law enforcement official for purposes such as: to identify/locate a suspect, material witness, fugitive or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes; regarding a crime victim in certain situations; concerning a death we believe has resulted from criminal conduct; regarding criminal conduct in our offices; in an emergency, to report a crime (including location or victim(s) of the crime or the description of the perpetrator).
15.  Coroner.  Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death.
16.  Organ or Tissue Donation.  Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation if you are an organ donor.
17.  Public Safety.  We may, and are sometime required by law to disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.  Under these circumstances, we will only make disclosures to a person or organization able to prevent the threat.
18.  Specialized Government Functions.  We may disclose your PHI as necessary for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
19. Workers’ Compensation.  Our practice may release your PHI as necessary to comply with workers’ compensation laws.  For example, to the extent that your care is covered by workers’ compensation, we will make periodic reports to your employer about your condition.  We are also required by law to report cases of occupational injury or occupational illness to the employer or workers’ compensation insurer.
20. Change of Ownership.  In the event this practice is sold or merged with another organization, your PHI will become the property of the new owner, although you will retain the right to request that copies of your PHI be transferred to another physician or medical group.

Except as described in the Notice of Privacy Practices, our practice will not use or disclose health information which identifies you without your written authorization.  If you do authorize this practice to use or disclose your PHI for another purpose, you may revoke your authorization in writing at any time.

1. Right to Request Confidential Communication.  You have the right to 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.
2. Right to Request Restrictions.  You have the right to request a restriction on certain uses or disclosures of your PHI, by a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish imposed.  We reserve the right to accept or reject your request, and will notify you of our decision.
3. Right to Inspect and Copy.  You have the right to inspect and obtain a copy of your PHI with limited exceptions.  To access your PHI, you must submit a written request specifying what information you want access to and whether you want to inspect or get a copy of it. Our practice may charge a fee as allowed by California law for the costs of copying, mailing, labor and supplies associated with your request.  Our practice may deny your request to inspect and/or copy in certain limited circumstances.  If we deny your access to your child’s records however, you may request a review of our denial.  If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.
4. Right to Amend or Supplement.  You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice.  To request an amendment, your request must be made in writing to this practice.  You must provide us with a reason that supports your request for amendment.  Our practice may deny your request if you fail to submit your request in writing.  Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for our practice, (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice.  You also have the right to add to your record a statement of up to 250 words concerning any statement or item you believe to be incorrect or incomplete.
5. Right to an Accounting of Disclosures.  All of our patients have the right to request an “accounting of disclosures,” meaning a list of certain disclosures our practice had made of your PHI, except that this practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (healthcare operations), 7 (release of information to friends/family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practice or disclosures for purpose of research or public health which exclude direct patient identifiers, or which are incidental to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement officials.  In order to obtain an accounting of disclosures, you must submit your request in writing to this practice; requests for accounting of disclosures must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003, and will be subject to a $35.00 fee.  Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6.  Right to a Paper Copy of This Notice.  You are entitled to receive a free paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with the privacy officer of this practice.  All complaints must be submitted in writing.  If you are not satisfied with the way this practice handles a complaint, you may submit a formal complaint to: Department of Health and Human Services, Office of Civil Rights. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Issues and Disclosures.  Our practice will obtain a written authorization for uses and disclosures that are not identified by this notice or applicable law.  Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing.  After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.  Please note we are required to obtain records for your care.
9. Right to be Notified in the Event of a Breach of Unsecured PHI. Our practice makes every effort to keep PHI protected and secure, however, if there is a breach that affects your PHI, you have the right to be informed of it.