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NOTICE OF PRIVACY PRACTICES

Rosaasen Family Medicine

187 E Wilbur Rd Suite 100, Thousand Oaks, CA 91360 | (805) 492-1015 | office@rosaasenmd.com

Effective Date: November 3, 2026

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.

YOUR RIGHTS

When it comes to your health information, you have certain rights. You can:

  • Get an electronic or paper copy of your medical record. Ask us how to do this. We will provide a copy or a summary, usually within 30 days of your request, and may charge a reasonable, cost-based fee.

  • Ask us to correct your medical record if you think it is incorrect or incomplete. We may say "no," but we will tell you why in writing within 60 days.

  • Request confidential communications, for example by contacting you at a different phone number or address. We will say "yes" to all reasonable requests.

  • Ask us to limit what we use or share for treatment, payment, or our operations. We are not required to agree if it would affect your care. If you pay for a service out-of-pocket in full, you can ask us not to share that information with your health insurer, and we will say "yes" unless a law requires us to share it.

  • Get a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why (excluding treatment, payment, operations, and certain other disclosures). One accounting a year is free.

  • Get a paper copy of this notice at any time, even if you agreed to receive it electronically.

  • Choose someone to act for you, such as a medical power of attorney or legal guardian.

  • File a complaint if you feel your rights are violated, by contacting us using the information above, or with the U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Avenue S.W., Washington, D.C. 20201, 1-877-696-6775, or www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. In these cases you have both the right and choice to tell us to share information with your family, close friends, or others involved in your care, and to share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest, or when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission: marketing purposes, sale of your information, and most sharing of psychotherapy notes.

OUR USES AND DISCLOSURES

We typically use or share your health information in the following ways:

  • Treat you: we can use your health information and share it with other professionals who are treating you.

  • Run our organization: we can use and share your health information to run our practice, improve your care, and contact you when necessary.

  • Bill for your services: we can use and share your health information to bill and get payment from health plans or other entities.

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research, when the law requires it (including the Department of Health and Human Services), to help with public health and safety issues (preventing disease, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, preventing or reducing a serious threat to anyone's health or safety), for research, to respond to organ and tissue donation requests, to work with a medical examiner or funeral director, to address workers' compensation, law enforcement, and other government requests, and to respond to lawsuits and legal actions.

California law may provide additional protections for certain information, such as mental health, HIV/AIDS test results, substance use disorder treatment, and genetic information. We follow those laws.

OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your protected health information.

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it.

  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time by letting us know in writing.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Privacy Officer contact: Rosaasen Family Medicine, 187 E Wilbur Rd Suite 100, Thousand Oaks, CA 91360, (805) 492-1015, office@rosaasenmd.com

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