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Privacy Notice

Our Pledge to Protect Your Privacy

Menlo Medical Clinic knows that medical information about you is personal and is committed to protecting the privacy of your information. As a patient of the Clinic, the care and treatment you receive is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with all the health care providers involved in your care. We share your information only to the extent necessary to conduct our business operations, to collect payment for the services we provide you and to comply with the laws that govern health care. We will not use or disclose your information for any other purpose without your permission.

Our Notice of Privacy Practices

Beginning April 14, 2003, the Clinic will provide you with a Notice of Privacy Practices that explains our privacy practices and your rights regarding your medical information. The first time you receive care on or after April 14, 2003, the Clinic will provide you with a copy of our Notice and ask you to acknowledge its receipt. The Clinic may need to change its privacy policies and practices from time to time and will update the Notice accordingly.

You may ask for a copy of our current Notice at any time in any of the patient registration areas throughout the Clinic, it is publicly posted in a number of places. You can also view and print a copy of our current Notice by clicking on Notice of Privacy Practices.

Throughout these web pages on patient privacy you may click on items that are in italics and underlined and an Adobe PDF file version of a document or form will open for your review or to be printed.

Your Rights Regarding Medical Information About You

An important part of the Clinic's Notice is the section that explains your rights regarding your medical information. Our Notice explains that you (or your personal representative) have the right to:

  • Inspect or Obtain a Copy of Your Medical Record: You have the right to inspect or obtain a copy of the medical records that the Clinic uses to make decisions about you and your treatment, subject to certain limitations. This information includes your medical and billing records, but may not include some mental health information. If you request a copy of your records, the Clinic may charge a fee for the cost of providing your records to you.

  • Request a Correction or Add an Addendum to Your Medical Record: If you believe that medical information the Clinic has on file about you is incorrect or incomplete, you may ask us to correct the medical information in your records. If your medical information is accurate and complete, or if the information was not created by the Clinic, we may deny your request; however, if we deny any part of your request, we will provide you with a written explanation of our reasons for doing so. Requests to make a correction to your records must be in writing and we recommend, but do not require, that you use the Clinic's Request for an Addendum or Correction form. Your written request must describe each item that you want changed (for example: History and Physical on 3/1/2003 and Clinic Visit Note on 4/14/2003) and the reason your are requesting the change.

In addition, an adult patient of the Clinic who believes that an item or statement in his/her medical record is incorrect or incomplete has the right to provide the Clinic with a written addendum to his/her record. The addendum is limited to 250 words per incorrect or incomplete item, and must clearly indicate that the patient wishes it to be made a part of his/her record. Requests to add an addendum must be in writing and we recommend, but do not require, that you use the Clinic's Request for an Addendum or Correction form.

Please send your request to Medical Records - Release of Information, 1300 Crane Street, Menlo Park, CA 94025 or fax your request to (650) 324-9447. Copies of the request forms and assistance are also available at the Clinic's Medical Records Department. The Medical Records Department will acknowledge your request when it is received and process your request within sixty (60) days of receipt. In certain situations the Medical Records Department may require an additional thirty (30) day extension to process your request.

  • An Accounting of Clinic Disclosures of Your Medical Information: You have the right to request an "accounting of disclosures" which is a list describing how we shared your medical information with outside parties. This accounting is a list of the disclosures we made of your medical information after April 14, 2003 for purposes other than treatment, payment and health care operations as described in our Notice of Privacy Practices.

 

You may request at no charge an accounting of disclosures once every twelve months. If you make more than one request in a twelve month period, the Clinic will charge a $50.00 processing fee for each additional request.

To request an accounting of disclosures, please print and complete the Request for Accounting of Disclosures Form. You may either mail the form to the Clinic Privacy Office, 1300 Crane Street Menlo Park , CA 94025 or fax it to (650) 324-9447. If you have questions about completing the form, please call 650.498-6644. Copies of the Request Form and assistance are also available at the Clinic's Release of Information Department on the Third Floor of the Clinic.

 

  • Receive a Copy of the Clinic's Privacy Notice: You may ask for a printed copy of the Clinic's Notice of Privacy Practices anytime you are visiting the Clinic. The Notice is available in the New Registration Office and registration areas. You may also print a copy of the Notice from this website by clicking on Notice of Privacy Practices.
  • Request Confidential Communications: The Clinic considers all of your medical and billing information to be confidential. You have the right to request that we communicate with you about medical and billing matters by an alternative method or at an alternative locations. For example, you may ask that we only contact you at work rather that at your home. The Clinic's Privacy Office will review all requests and accept those that we may reasonably accommodate. The Clinic will not ask the reason for your request, but we may ask questions regarding how payment will be handled. If your request is accepted, it will apply to all our communications regarding treatment you receive from the acceptance date forward. Your request will be in effect until you change or withdraw it by submitting a new copy of the form.

To make a confidential communications request, please print and complete a Request for Confidential Communications Form. You may either mail the form to the Clinic Privacy Office, 1300 Crane Street ,Menlo Park, CA 94025 or fax it to 650.324-9447. If you have questions about completing the form, please call 650.498-6644. Copies of the Request Form and assistance are also available at the Clinic's Release of Information Office. Alternative, you may request confidential communications during the registration process at the Clinic.

To change or withdraw a prior request for confidential communications you must complete and submit a new Request for Confidential Communications Form and indicate that you are changing or withdrawing a prior request.

For further information, please view these documents:

Notice of Privacy Practices

Request for Confidential Communications Form

Request for Accounting of Disclosures Form

Request for an Addendum or Correction