THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all records of your care generated and maintained by Bristol Park Medical Group, Inc. and/or Bristol Park Medical Management, L.P. (collectively referred to in this Notice as "Bristol Park Medical Group"). Your hospital or non-Bristol Park Medical Group providers may have different policies or notices about the use and disclosure of information in their possession.

We are required by law to: 1) make sure that medical information that identifies you is kept private; 2) make available to you this Notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the Notice that is currently in effect.

• We may disclose medical information about you to doctors, nurses, medical students, or other Bristol Park Medical Group personnel involved in taking care of you. We may also disclose medical information to people outside the medical group, such as family members, specialists or others who are involved in providing services that are part of your care.
• We may use or disclose medical information about you so that the treatment and services you receive at Bristol Park Medical Group may be billed to and payment may be collected from you, an insurance company or a third party.
• We may use or disclose medical information about you for Bristol Park Medical Group operations. These may include use of information to evaluate the performance of our staff, effectiveness of programs, and ways to improve care and services we offer. These uses and disclosures are necessary to ensure that all of our patients receive quality care.
• We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care at Bristol Park Medical Group.
• We may use or disclose medical information to tell you about or recommend possible treatment options or alternatives, and about health-related benefits and services that may be of interest to you.
• We may disclose medical information about you to other healthcare providers in the event you need emergency care.
• We will disclose medical information about you as required by federal, state or local law.
• We may use or disclose medical information to a public health organization or federal organization when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• We may use or disclose medical information about you in special situations such as for organ donation purposes; workers' compensation programs; as required by military command authorities or the Department of Veterans Affairs; to law enforcement in response to a warrant or other request permitted by law; in response to a court or administrative order; to coroners, medical examiners and funeral directors; to correctional institutions; to a health oversight agency for activities authorized by law; to federal officials to conduct national security activities or to protect the President and others; or for public health activities including to report births and deaths, to report victims of abuse or neglect, to report reactions to medications or notify people of product recalls, and to prevent or control disease or injury.
• Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. You may revoke this permission in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

• You have the right to review and receive a copy of medical information that may be used to make decisions about your care. Usually this includes medical and billing records, but does not include psychotherapy notes. You must submit a written request to review and copy your medical information. We may charge a fee for the costs of supplying a copy of the records. We shall provide access to information in the format requested, including electronic format for any record maintained electronically, or we will give you a readable hard copy or other mutually agreed upon format.
• You have the right to ask us to amend medical information that you feel is incorrect or incomplete. Your request for an amendment must be submitted in writing and must provide a reason that supports your request.

  We may deny your request for 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 the information: 1) was not created by us; 2) is not part of the medical information kept by or for Bristol Park Medical Group; 3) is not part of the information which you are permitted to inspect and copy; or 4) is accurate and complete.

• You have the right to request an "accounting of disclosures." This is a list of disclosures we have made of medical information about you, with some exceptions. The exceptions are governed by federal health privacy law, and include: 1) routine disclosures for treatment, payment and operations conducted pursuant to your signed consent form; and 2) disclosures to you. You must submit a written request. The request must state a time period that may not be longer than six years and may not include dates before April 14, 2003, when current federal health privacy laws become effective for Bristol Park Medical Group. You have a right to receive a free copy of this list once a year. For additional lists, we may charge you for the costs of providing the list. 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 restrictions or limitations on the use or disclosure of medical information about you. You must submit a written request for restriction that specifies: 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. All requests to restrict disclosure of PHI to a health plan for payment or healthcare operations where the patient has paid fully out of pocket for the services shall be granted.

  Bristol Park Medical Group reserves the right to refuse your restriction if it is in conflict of providing you quality healthcare or in an emergency situation.

• You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, such as only at work or by mail. You must submit a written request for confidential communications restrictions, specifying how or where you wish to be contacted. We will accommodate reasonable requests.
• You have the right to possess a copy of this Notice upon request. You may receive a paper copy of this Notice, or you can also obtain a copy of this Notice at our website, www.bristolparkmed.com.
• You have the right to file a complaint with Bristol Park Medical Group or the Secretary of the U.S. Department of Health and Human Services if you believe your rights to privacy have been violated. To file a complaint with Bristol Park Medical Group, contact the Chief Privacy Officer at the address noted at the end of this Notice. All complaints must be submitted in writing. All complaints will be investigated. No personal issue will be raised for filing a complaint.

Bristol Park Medical Group reserves the right to change this Notice at any time. We will post a copy of the current notice in our clinical sites and on our website.

If you have any questions about this Privacy Notice, please contact:

Attn: Chief Privacy Officer
Bristol Park Medical Group, Inc.
2742 Dow Avenue
Tustin, CA 92780
Tel: (714) 665-1600