EFFECTIVE DATE: April 14, 2003


Understanding your health record

A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examination and test results, diagnoses, treatment, and a plan for future care are recorded. This information is most often referred to as your “health or medical record,” and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professional who may contribute to your care. Understanding what information is retained in your record and how that information may be used will help you to ensure its accuracy, and enable you to relate to who, what, when, where, and why other may be allowed access to your health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others. Use or disclosure of your health information will follow the more stringent of State of Federal laws.

Understanding your health information rights

Your health record is the physical property of the health care practitioner or facility that compiled it but the content is about you, and therefore belongs to you. You have the right to request restrictions on certain uses and disclosures of your information, and to request amendments be made to your health record. Your rights include being able to review or obtain a paper copy of your health information, and to be given an account of all disclosures. You may also request communications of your health information be made by alternative means or to alternative locations. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose your health information.

Our responsibilities

This office is required to maintain the privacy of your health information and to provide you with notice of our legal commitments and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions of reasonable desires to communicate your health information by alternative means or to alternative locations.
This office reserves the right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will post changes on our web site that provides information about our customer service and/or benefits.
Other than for reason described in this notice, this office agrees not to use or disclose your health information without your authorization.

To receive additional information or report a problem

For further explanation of this notice you may contact; Hoyman Hong, M.D. If you believe your privacy rights have been violated, you have the right to file a complaint with this office by contacting the individual above, or by contacting the Secretary of Health and Human Services, with no fear or retaliation by this office.

Your health information will be used for treatment, payment, and health care operations.

Treatment – Information obtained by your health practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your physician recording his/her own expectations and those of others involved providing your care. The sharing of your health information may progress to others involved in your care, such as specialty physicians or lab technicians.

Payment – Your health care information will be used in order to receive payment for services rendered by this office. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used.

Health Care Operations – The medical staff in this office will use your health information to assess the care you received and the outcome of your case compared to others like it. Your information may be received for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.

Understanding our office policy for specific disclosures

Business Associates – Some or all of your health information may be subject to disclosure through contracts for services to assist this office in providing health care. For example, it may be necessary to obtain specialized assistance to process certain laboratory tests or radiology images. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.

Notification – Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well-being or your whereabouts.
Communications with Family – Using best judgment, a family member, or close personal friend, identified by you, may be given information relevant to your care and/or recovery.

Funeral Directors – Your health information may be disclosed consistent with laws governing mortician services.

Organ Procurement Organizations – Your health information may be disclosed consistent with laws governing entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation or transplant.

Marketing – This office reserves the right to contact you with appointment reminders or information about treatment alternatives and other health-related benefits that may be appropriate to you.

Patient Directory (typically applicable only to inpatient settings) – Unless you object, this facility will use your name, room number, general condition, and religious affiliation for directory purposes. This information will be made available to clergy, and others who ask for you by name.

Research (typically applicable only to inpatient settings) – Your information will be disclosed to researchers upon Institutional Review Board approval, and upon the assurance that established protocol to ensure the privacy of your health information has been obtained.

Food and Drug Administration (FDA) – This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defeats for surveillance to enable product recalls, repairs, or replacements.

Worker’s Compensation – This office will release information to the extent authorized by law in matters of workers compensation.

Public Health – This office requires by law to disclose health information to public health and/or legal authorities charges with tracking reports of birth and morbidity. This office if further required by law to report communicable disease, injury, or disability.

Correctional Facilities – This office will release medical information on incarcerated individuals to correctional agents or institutions for the necessary welfare of the individual or for the health and safety of other individuals. The rights outlined in this Notice of Privacy Practices will be not extended to incarcerated individuals.

Law Enforcement – (1) Your health information will be disclosed for law enforcement purposes as required under state law or in response to a valid subpoena. (2) Provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys in the event that a staff member of business associate of this office believes in good faith that there has been unlawful conduct or violations of professional or clinical standards that may endanger one or more patients, workers, or the general public.


The term described in this notice will be posted where registration occurs. All individuals receiving care will be given a hard copy.

Patient Comments:


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Patient (Parents, Guardian) Signature Date