SHIELD HEALTHCARE, INC.
NOTICE OF PRIVACY PRACTICES

This Notice was published and becomes effective on April 14, 2003.

This Notice of Privacy Practices specifies how Shield Healthcare, Inc. may use and disclose your protected health information to obtain payment for medical billings and for other purposes as permitted or required by law.  It also specifies your rights to access your protected health information.  Protected health information is personal information about you including demographic information that may identify you.

Uses and Disclosures of Protected Health Information

PAYMENT
Your protected health information will be used, as needed, to obtain payment for your health care services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services for you such as eligibility and review activities.

OPERATIONS
Your protected health information may be shared with business associates. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Your protected health information may be used to provide you with information about other health-related benefits and services that may be of interest to you.  We may also use your protected health information to send you information about products or services that may be beneficial to you. You may request that these materials not be sent to you, by writing to our Privacy Contact indicated below.

Your protected health information will be disclosed when Shield Healthcare, Inc. is required to do so by federal, state, or local law for law enforcement purposes. Information may be disclosed in response to a court or administrative order, a subpoena, a discovery request, or other lawful process.

BASED UPON YOUR WRITTEN AUTHORIZATION
Other uses and disclosures of your protected health information will only be made with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, by writing to our Privacy Contact indicated below.

Individual Rights to Access Your Protected Health Information

1. You have the right to request restrictions on certain uses and disclosures of protected health information. Your request must state the specific restriction requested. Shield Healthcare, Inc. is not required to agree to a requested restriction.
   
2. You have the right to request and receive confidential communications of protected health information, as applicable.
   
3. You have the right to inspect and obtain a copy of your protected health information about you for as long as it maintained. Shield Healthcare will accommodate reasonable requests. Shield Healthcare, Inc. may condition any accommodation by specifying an alternative address for review of records or a method of contact.
   
4. You have a right to request an amendment to your protected health information.
   
5. You have the right to request and receive an accounting of disclosures of protected health information for reasons other than payment or operations.
   
6. You have the right to obtain a paper copy of this notice from Shield Healthcare, Inc. upon request.

You may exercise these rights by sending a written request to the Privacy Contact indicated below.

Complaints

1. If you believe your privacy rights have been violated, you may file a complaint with Shield Healthcare, Inc., by writing to our Privacy Contact indicated below or the Secretary of the Department of Health and Human Services.
   
2. All complaints must be submitted in writing.
   
3. You will not be penalized for filing a complaint.

Privacy Contact
Privacy Officer
Shield Healthcare, Inc.
27911 Franklin Parkway
Valencia, CA  91355
661/294-4200
www.shieldhealthcare.com

Shield Healthcare, Inc. is required by law to maintain the privacy of protected health information and provide individuals with notice of its legal duties and privacy practices with respect to protected health information.  Shield Healthcare, Inc. is required to abide by the terms of the Notice currently in effect.  Shield Healthcare, Inc. reserves the right to change the terms of this notice and to make a new notice with provisions effective for all protected health information that it maintains. If revised, a copy will be provided to you.

If you have not already done so, please download and sign a printable copy of this document and return this agreement to acknowledge your receipt to the address noted above.

To download a printable copy of this document, click here.