The DRIVE Wellness website and clinics are provided and operated by Crossover Health Medical Group, APC for HEB and its Partners. Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will receive information and create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices (the “Notice”). Any revision or amendment to the Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our clinics in a visible location at all times, and you may request a copy of our most current Notice at any time. A revised Notice may be obtained by forwarding a written request to Crossover Health Medical Group, 65 Enterprise, Suite 355B, Aliso Viejo, CA 92656.
We keep records of the medical care we provide you, and we may receive similar records from others. We use this information so that we, or other health care providers, can render quality medical care, obtain payment for services and enable us to meet our professional and legal responsibilities to operate our medical practice. We may store this information in a chart and in our computers. This information makes up your medical record. The medical record is our property; however, this notice explains how we use information about you and when we are allowed to share that information with others.
Crossover Health Medical Group
65 Enterprise, Suite 355B
Aliso Viejo, CA 92656
The following categories describe the different ways in which we may use and disclose your PHI.
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
We want to make you aware that, just as Crossover Health Medical Group uses and discloses certain PHI in your treatment, our operations and management and certain payment practices, Crossover Health Medical Group receives PHI from other healthcare entities and their business associates including but not limited to: medical files, charts, laboratory testing results, imagining results, and insurance claims data. PHI that is received and maintained by Crossover Health Medical Group from outside entities is subject to the protections of relevant law and our HIPAA and HITECH policy.
Except as described in this Notice, or as otherwise permitted by law, we must obtain your written permission – called an authorization – prior to using or sharing health information that identifies you as an individual. If you provide an authorization and then change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share your health information as outlined in the authorization form; however you should be aware that we won’t be able to retract a use or disclosure that was previously made in good faith based on what was then a valid authorization from you.
Except as specified above, under California law we may not share your health information with your employer or benefit plan unless you provide us an authorization to do so.
You have the following rights regarding the PHI that we maintain about you:
Your request must describe in a clear and concise fashion:
You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Again, if you have any questions regarding this Notice or our health information privacy policies, please contact Crossover Health Medical Group at (949) 891-0328.
I acknowledge that I have received the Notice of Privacy Practices for Crossover Health Medical Group, and have been provided an opportunity to review it. If you have any questions or would like a hard copy of this Notice, please ask for one at the front desk or contact Crossover Health Medical Group at (949) 891-0328.
I hereby give my consent for Crossover Health Medical Group to receive, use and disclose Protected Health Information (“PHI”) about me, including but not limited to medical charts, records, laboratory results, imaging results, insurance claims data and information, to carry out treatment, payment and health care operation (“TPO”) as described in the Notice of Privacy Practices. I recognize the need for medical care; authorize the Crossover Health Medical Group to render such medical and ancillary care, tests, procedures, drugs and other services and supplies under the general and specific instruction of the Crossover Health Medical Group. Except for emergency or extraordinary circumstances, it is my understanding that additional consents will be obtained by my treating physician if more invasive services are to be performed or if additional consents or authorizations are required by law. I understand and am aware that the practice of medicine is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination. I understand that it is my right to consent, or to refuse consent, to any proposed procedure or therapeutic course.
I understand that Crossover Health Medical Group uses advanced technology to deliver quality care, and I consent to the use of this technology. If you have any questions regarding the technology used by Crossover Health Medical Group, please contact Crossover Health Medical Group at (949) 891-0328.
Also, with this consent Crossover Health Medical Group may:
As a partner in my health care, I have the following responsibilities:
I hereby consent to the sharing of any and all Apple Wellness data pertaining to me, which may include my health information, with (1) Crossover Health Medical Group, and (2) any and all health care providers affiliated with the Apple Wellness Center, including but not limited to physical therapy, acupuncture and chiropractic providers, for purposes of carrying out and coordinating my treatment and other health care operations.
I consent to share claims data, which may contain my Protected Health Information, with Crossover Health Medical Group for the purposes of carrying out treatment and other health care operations as described in the Notice of Privacy Practices and consistent with the General Consent.