Pacific Orthopaedic Institute

A Professional Corporation

5230 Pacific Concourse Dr.,Suite 110

Los Angeles, California90045

Phone 310 643-0821 Fax 310 643-7546

Jeffrey A. Bogosian, M.D. Julian E. Girod, M.D.

Diplomate, American Board of Orthopaedic Surgery Diplomate, American Board of Orthopaedic Surgery

Fellow, AmericanAcademy of Orthopaedic Surgeons Sports Medicine Fellowship Trained

SUMMARY OF OUR PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE HANDLED IN THIS PRACTICE.

Please review the full Notice of Privacy Practices (NPP)which is attached. If you have any questions about this notice please contact our office manager.

We understand that health information is personal and we are committed to protecting health information about you. We create a record of the care and services you receive from us. We need a complete record to provide you with quality care and to comply with legal requirements. This notice applies to all records of your care generated by this practice whether made by your personal physician or other health care workers in this office. This notice will tell you about the ways in which we may use and disclose health information about you.

We are required by law to;

1. make sure that the health information that identifies you is kept private,

2. give you this notice of our legal duties and privacy practices which we must follow.

By allowing us to care for you, you give us the right to use your information for treatment, to get reimbursed for your care and to operate our organization.

We may disclose information about your care to:

allow oversight of the quality of health care we provide
allow workers compensation claims
comply with subpoenas, as required by law
avert serious threat to health or safety.

You have the right to inspect health information we have gathered on you, by written request and by appointment only. You may amend in writing any information in your medical file. You may request a list of specific disclosures. You may request restrictions or confidential communication of your records. For details on these issues please talk with our Office Manager.

We reserve the right to change/amend this notice as it applies to any and all medical records held by this practice.

If you believe your Privacy Rights have been violated you may file a complaint with this office or with the Department of Health and Human Services. All complaints must be in writing and should be addressed to the Office Manager.

Other uses and disclosures of health information, not covered by this notice, will be made only with your written permission. If you provide us permission to disclose information about you, you may revoke that permission in writing at any time.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , have received a copy of the Notice of Privacy Practices from Pacific Orthopaedic Institute, A Professional Corporation; Jeffrey Bogosian, M.D. and Julian Girod, M.D.

X______Date: ______

Patient Signature

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In lieu of patient’s signature, I ______, a staff member of Pacific Orthopaedic Institute, A Professional Corporation state that ______has been given our current Notice of Privacy Practices.

X ______Date:______

Employee Signature