Terms and Conditions

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, from other sources of coverage such as an automobile insurer, or from 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 services 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 medical practice. 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 will 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 on 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.

‍

Fund raising. Unless you request us not to, we will use your name and address to support our fund-raising efforts. If you do not want to participate in fund-raising efforts, please check off the following box.

‍

Individual Rights

‍You have certain rights under the federal privacy standards. These include the following and are explained in greater detail in the PATIENT RIGHTS section of this notice:

‍

• the right to request restrictions on the use and disclosure of your protected health information
• the right to receive confidential communications concerning your medical condition and treatment
• the right to inspect and copy your protected health information
• the right to amend or submit corrections to your protected health information
• the right to receive an accounting of how and to whom your protected health information has been disclosed
• the right to receive a printed copy of this notice

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. These 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 protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our receptionist or privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

David Ehrlich, Privacy Officer

Epione Medical Corporation

444 North Camden Drive

Beverly Hills, CA 90210

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.

The name and address of the person you can contact for further information concerning our privacy practices is:

David Ehrlich, Privacy Officer

Epione Medical Corporation

444 North Camden Drive

Beverly Hills, CA 90210

Effective Date

This Notice is effective on or after April 14, 2003.

You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate, legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed.

‍

To inspect and copy your medical record, you must submit your request in writing to our Privacy Officer. Ask the front desk person for the name of the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request.

‍

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you will be given a written explanation of the denial of your request. You will be also given an opportunity to request a review of that decision by a licensed professional chosen by the practice who was not involved in the original decision to deny the request. The practice will complete this review with 30 days and the results will be communicated to you.

If you feel that the medical information we have about you in your record is incorrect or incomplete, then you may ask us to amend the information, following the procedure below. You have the right to request an amendment for as long as the Practice maintains your medical record.

‍

To request an amendment, your request must be submitted in writing, along with your intended amendment and a reason that supports your request to amend. The amendment must be dated and signed by you. The Practice has a specific form available for this purpose.

‍

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

Is not part of the medical information kept by or for the Practice;

Is not part of the information which you would be permitted to inspect and copy; orIs inaccurate and incomplete.

You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of medical information about you, to others.

To request this list, you must submit your request in writing. Your request must state a time period not longer than six (6) years back and may not include dates before April 14, 2003 (the actual implementation date of the HIPAA Privacy Regulations). Your request should indicate in what form you want the list (for example, on paper, electronically). We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend). For example, you could ask that we not use or disclose information about a particular treatment you received.

We are not required to agree to your request and we may not be able to comply with your request. If we do agree, we will comply with your request except that we shall not comply, even with a written request, if the information is excepted from the consent requirement or we are, otherwise required to disclose the information by law.

‍

To request restrictions, you must make your request in writing. In your request, you indicate:

What information you want to limit;

Whether you want to limit our use, disclosure or both; and

To whom you want the limits to apply, (e.g., disclosures to your children, parents, spouse, etc.)

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, that we not leave voice mail or e-mail, or the like.

‍

To request confidential communications, you must make your request in writing. 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 us to contact you.

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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To file a notice of infringing material on a site owned or controlled by Epione Medical Corporation please provide a notification containing the following details:

• Reasonably sufficient details to enable us to identify the work claimed to be infringed or, if multiple works are claimed to be infringed, a representative list of such works (for example: title, author, any registration or tracking number, URL);
• Reasonably sufficient detail to enable us to identify and locate the material that is claimed to be infringing (for example a link to the page that contains the material);
• Your contact information so that we can contact you (for example, your address, telephone number, email address);
• A statement that you have a good faith belief that the use of the material identified in (2) is not authorized by the copyright owner, its agent, or the law;
• A statement, under penalty of perjury, that the information in the notification is accurate and that you are authorized to act on behalf of the owner of the exclusive right that is alleged to be infringed.
• Your physical or electronic signature.

‍

Then send this notice to

‍

By Mail:
Epione Medical Corporation
Attn.: DMCA Agent
444 North Camden Drive
Beverly Hills, CA 90210

By Fax:
Attn: DMCA Agent, Epione Medical Corporation
+1.310. 271-3786

By Email:
Email: david@epione.com

If material that you have posted to a site controlled or operated by Epione Medical Corporation has been taken down, you may file a counter-notification that contains the following details:

• Identification of the material that has been removed or to which access has been disabled and the location at which the material appeared before it was removed or disabled;
• A statement, under penalty of perjury, that you have a good faith belief that the material was removed or disabled as a result of mistake or misidentification of the material in question;
• Your name, address and telephone number;
• A statement that you consent to the jurisdiction of the Federal District Court for judicial district in which your address is located or, if your address is outside of the USA, for any judicial district in which Creative Commons may be found and that you will accept service of process from the person who submitted a notice in compliance with the section (c)(1)(C) of the DMCA, as generally described above;
• Your physical or electronic signature.

‍

Then send this notice to:

‍

By Mail:
Epione Medical Corporation
Attn.: DMCA Agent
444 North Camden Drive
Beverly Hills, CA 90210

By Fax:
Attn: DMCA Agent, Epione Medical Corporation
+1.310. 271-3786

Email: david@epione.com

‍

You may be able to find examples of counter-notifications at www.chillingeffects.org/dmca/counter512.pdf. Please note, however, that this is no substitute for legal advice and you should obtain legal advice to better understand your rights and obligations under the DMCA and applicable laws.

You have the right to request an “accounting of disclosures”. This is a list of the disclosures we made of medical information about you, to others.

To request this list, you must submit your request in writing. Your request must state a time period not longer than six (6) years back and may not include dates before April 14, 2003 (the actual implementation date of the HIPAA Privacy Regulations). Your request should indicate in what form you want the list (for example, on paper, electronically). We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend). For example, you could ask that we not use or disclose information about a particular treatment you received.

We are not required to agree to your request and we may not be able to comply with your request. If we do agree, we will comply with your request except that we shall not comply, even with a written request, if the information is excepted from the consent requirement or we are, otherwise required to disclose the information by law.

‍

To request restrictions, you must make your request in writing. In your request, you indicate:

What information you want to limit;

Whether you want to limit our use, disclosure or both; and

To whom you want the limits to apply, (e.g., disclosures to your children, parents, spouse, etc.)

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, that we not leave voice mail or e-mail, or the like.

‍

To request confidential communications, you must make your request in writing. 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 us to contact you.

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. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.