JumpstartMD (“Jumpstart”, “our”, “ours”, or “we”) understands the importance of privacy and is committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information (the “Notice”), and to notify affected individuals following a breach of unsecured protected health information. This Notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our member services team listed at this bottom of this notice.

We reserve the right to make changes to this Notice as permitted by law. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page. If we change this Notice, you can access the revised Notice on our website, available here.

TABLE OF CONTENTS

1. How This Medical Practice May Use or Disclose Your Health Information
2. When This Medical Practice May Not Use or Disclose Your Health Information
3. Right to Request Special Privacy Protections
4. Right to Request Confidential Communications
5. Right to Inspect and Copy
6. Right to Amend or Supplement
7. Right to an Accounting of Disclosures
8. Right to a Paper or Electronic Copy of this Notice
9. Changes to this Notice of Privacy Practices
10. Complaints

1. How This Medical Practice May Use or Disclose Your Protected Health Information
This medical practice collects health information about you and stores it in electronic and paper forms. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We use medical information about you to provide your medical care. For example, we may share your medical information with other physicians or other health care providers who are involved in your care to coordinate or manage your health care services or to facilitate consultations or referrals as part of your treatment.
2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, as an out of network provider, we may give your health plan information it requires to help subsidize your care.
3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. These uses and disclosures are necessary to run our business and make sure our patients receive quality care. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. We may also share your medical information with our “business associates”, such as a billing service, that perform administrative services for us. In these cases, we have a written contract with each of these business associates to ensure they protect the privacy of your health information.
4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine at the phone number or email provided on your patient agreement.
5. Sign In Sheet. On rare occasions, we may use and disclose medical information about you by having you sign in with your first name and last initial when you arrive at our office. We may also call out your name when we are ready to see you.
6. Notification and Communication with Family. In limited circumstances, we may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location or your general condition if needed. We may also disclose limited information to someone who is involved with your care or helps pay for your care. In these circumstances, the health information we disclose would be limited to the health information that is relevant to that person’s involvement in your care or payment for your care.
7. Psychotherapy Notes. JumpstartMD will not maintain any psychotherapy notes.
8. Marketing. We will not otherwise use or disclose your medical information for marketing purposes without your prior written authorization. If authorized, we may contact you to give you information about products or services related to your treatment or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We will not receive any financial remuneration or other payment in connection with that marketing. We may similarly describe products or services provided by this practice. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, or encourage you to purchase a product or service when we see you, for which we may be paid. We will not otherwise use or disclose your medical information for marketing purposes without your prior written authorization.
9. Sale of Health Information. We will not sell your health information without your prior written authorization.
10. Required by Law. We will use and disclose your health information as required by law, but we will limit our use or disclosure to the relevant requirements of the law.
11. Public Health. We may disclose your health information to public health agencies as authorized by law. For example, we may report certain communicable diseases to the state’s public health department.
12. Reporting Victims of Abuse or Neglect. We may disclose health information to the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence. We only make this disclosure if you agree or when we are required or authorized by law to make the disclosure.
13. Health Oversight Activities. We may and are sometimes required by law to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.
14. Law Enforcement. We may and are sometimes required by law to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
15. Coroners. We may disclose your health information to coroners, medical examiners, or funeral directors in connection with their investigations of deaths or so that they can carry out their duties.
16. Public Safety. We may and are sometimes required by law to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
17. Specialized Government Functions. In certain circumstances, HIPAA authorizes us to use or disclose your health information to authorized federal officials for the conduct of national security activities and other specialized government functions.
18. Workers’ Compensation. We may disclose your health information as necessary to comply with laws regarding workers’ compensation or other similar programs.
19. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
20. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.

Please be aware that other state and federal laws may have additional requirements that we must follow or may be more restrictive than HIPAA on how we use and disclose certain of your health information. If there are specific more restrictive requirements, even for some of the purposes listed above, we may not disclose your health information without your written permission as required by such laws. For example, we will not disclose your HIV, STD, or other communicable disease related information without obtaining your written permission, except as permitted by law. We may also be required by law to obtain your written permission to use and/or disclose your mental illness, developmental disability, or alcohol or drug abuse treatment records or your genetic test results.

2. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

3. Right to Request Special Privacy Protections.
You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us
not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

4. Right to Request Confidential Communications.
You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications. We will not ask you the reason for your request.

5. Right to Inspect and Copy.
You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances.

6. Right to Amend or Supplement
You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice’s denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information. These written statements will become a part of your medical record.

7. Right to an Accounting of Disclosures.
You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 17 (specialized government functions) above in this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities. We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

8. Right to a Paper or Electronic Copy of this Notice.
You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail. If you would like to have a more detailed explanation
of these rights or if you would like to exercise one or more of these rights, contact our Member Services Team listed at the bottom of this Notice of Privacy Practices.

9. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. Changes to the Notice of Privacy Practices will be communicated via email and we will post a copy of the Notice of Privacy Practices available at the front desk in our offices. A copy will be available upon request.

10. Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Member Services Team listed below:
JumpstartMD Member Services
350 Lorton Avenue
Burlingame, CA 94010
www.jumpstartmd.com
(650) 241-6599
[email protected]

If you are not satisfied with the manner in which your complaint is handled, you may submit a formal complaint to the U.S. Department of Health and Human Services, Office for Civil Rights Online Complaint Portal at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

You will not be penalized in any way for filing a complaint.

We are privileged to serve you and look forward to supporting you on a journey to better health and well-being.