Armen A. Kassabian, M.D.
Board-Certified Urological Surgeon

NOTICE OF PRIVACY PRACTICES

Effective date: April 14, 2003

Armen A. Kassabian, M.D., Inc. may use and disclose protected health information for treatment, payment and healthcare operations. Examples include, but not limited to, home health agencies and/or referral to other providers for treatment, insurance companies for claims and collection agencies. Healthcare operations include, but not limited to, internal quality control and auditing of records.

Armen A. Kassabian, M.D., Inc. is permitted or required to use or disclose protected health information without the individual's written authorization in certain circumstances. Two examples are for public health requirements or court orders. We may release protected health information about you for workers' compensation or similar programs.

Armen A. Kassabian, M.D., Inc. will not make any other use or disclosure of a patient's protected health information without the individual's written authorization. Such authorization may be revoked at any time. Revocation must be written.

Armen A. Kassabian, M.D., Inc. may at times contact its patients to provide appointment reminders or information regarding treatment alternatives or other health-related benefits and services that may be of interest to the individual patient. We may use protected health information to contact you in regards to clinical research studies in an effort to enhance patient care and conduct clinical trials in our practice. We may disclose protected health information to the related pharmaceutical companies, its monitors and institutional review boards. If you do not want us to contact you for clinical research studies, you must notify our practice in writing.

We may release protected health information about you to those who are involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends the condition that you are in. You will be provided a form to list specific people who we may speak to regarding your medical care. In addition, we may disclose protected health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Armen A. Kassabian, M.D., Inc. reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains.

Armen A. Kassabian, M.D., Inc. will provide each patient with a copy of any revisions of its Notice of Information Practice at the time of their next visit, or at their last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.

Anyone may file a complaint to the Practice and to the Dept. of Health and Human Services, Office of Civil Rights if they believe their privacy rights have been violated. To file a complaint with the practice, please contact the Privacy Officer: Armen A. Kassabian, M.D. 818-845-0611. All complaints will be addressed and the results will be reported to the managing physician.

Patients have been granted individual rights under the HIPAA Legislation. These include the following:

You have the right to inspect and copy protected health information that may be used to make decisions about your care. This does not include information compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding, or Protected Health Information that is subject to or exempt from the Clinical Laboratories Act of 1988. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer listed above. If you request a copy of the information, we may charge a fee for the costs of copying: including mailing, labor, and other supplies associated with your request.

If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information, your request must be made in writing to the Privacy Officer. You must provide a reason that supports your request and we may deny your request if it is not in writing or does not include a reason to support the request. We cannot amend information that was not created by us, or is accurate and complete. We may deny your request to inspect and copy in very limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our organization will review your request and the denial. The person conducting the review will not be the person who denied your request and we will comply with the outcome of the review.

You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you that was not made for treatment, payment and health care operations, there are certain exceptions to this right.

To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer listed above. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. This list will be provided for free. The accounting must be provided to you no later than 60 days after the receipt of your request, unless we utilize the 30-day extension period.

You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, research or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. 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 the Privacy Officer listed above. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Either you or we may terminate the restriction upon notification of the other.

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location like your home or work. To request confidential communications, you must make your request in writing to the Privacy Officer listed above. 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.

You will be asked to sign an acknowledgement of receipt of this Notice of Privacy Practices. You will also be asked to outline or define specific instances or information that you would like kept completely confidential - between you and Armen A. Kassabian, M.D., Inc. If you have any questions regarding this Notice of Privacy Practices, please do not hesitate to contact our Privacy Officer for more information or clarification.


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Armen A. Kassabian, M.D.
2701 W. Alameda Avenue
Suite 506
Burbank, CA 91505
Tel: 818.845.0611
Fax: 818.845.0051
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