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Privacy Policy



This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We will:
keep medical information about you private, as provided by law; provide, or make available, as applicable, this notice of our legal duties and privacy practices with respect to medical information about you; notify affected individuals following a breach of unsecured protected health information; and follow the terms of the notice that are currently in effect. How we may use and disclose medical information about you. We will share medical information about you for purposes of treatment (such as sending medical information about you to your physician or to a specialist as part of a referral); to obtain payment for treatment (such as submitting information that identifies you and your diagnosis to a payer or Medicare); and to support health care operations (such as using information about you to assess the quality of care we have provided, utilization and patient satisfaction review).

We may use health information about you without your prior authorization for several other reasons. Subject to applicable law, we may give out medical information about you to other entities to carry out their duties for (a) public health purposes (such as births, deaths, public health surveillance); (b) abuse, neglect or domestic violence reporting; (c) health oversight audits or inspections; (d) research studies; (e) coroners or medical examiner services; (f) funeral arrangements; (g) organ donation; (h) tracking of FDA-regulated products; (i) workers’ compensation purposes; and (j) emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders.

We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you. We may contact you to support fundraising efforts and you have the ability to opt out of receiving such communications. We may disclose medical information about you to a friend or family member who is involved in your medical care, to others whom you designate as involved in your medical care, or to disaster relief authorities so that your family can be notified of your location and condition.

Before we make any use or disclosure of your protected health information for marketing purposes, any disclosure that constitutes a sale of your protected health information, or in any other situation not covered by this notice where we may wish to use or disclose medical information about you, we will ask for your written authorization. You can later revoke your authorization by notifying us in writing.

Your rights regarding medical information about you

In most cases, when you submit a written request, you have the right to look at or get a copy of medical information that we use to make decisions about your care. We will provide you a form that you can complete to make the request. If you request copies of the information, however, we may charge a fee for cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.

If you believe that information in our records about you is incorrect or if important information is missing, you have the right to request that we amend the records, by submitting a request in writing and including your reason for requesting the amendment. We will provide you a form that you can complete to make the request. We may deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine the record is complete and accurate. If we deny your request to amend, you may submit a written request to review that denial. You have the right to make a written request to us for a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure. Your request must state the time period desired for the accounting, which must be less than a 6-year period starting after April 14, 2003. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before charging you.

You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to communicate with you.

You have the right to restrict us from disclosing medical information about you to a health plan when you pay out of pocket in full for the health care item or service.

You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but our processes may not be able to accommodate it and we are not legally required to agree to your request. We will inform you of our decision on your request.

All written requests or requests for review of denials should be submitted to our Privacy Officer identified at the bottom of this notice.


If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer (listed below), or you may send a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights. Our Facility Privacy Officer can provide you the address. Under no circumstance will you be penalized or retaliated against for filing a complaint.

Privacy Officer: Austin Harris, MD

NeuroRelief: Ketamine & Infusion Therapy

4955 Van Nuys Blvd, Ste 411

Sherman Oaks, CA 91403

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