Policies and Terms

JENNIFER LANG, M.D.

OBSTETRICS, GYNECOLOGY, GYNECOLOGIC ONCOLOGY

PATIENT NOTIFICATION OF THE USE AND DISCLOSURE OF MEDICAL INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

I understand that this information serves as:

A basis for planning my care and treatment.
A means of communication among the many healthcare professionals who contribute to my care.
A source of information for applying my diagnosis and surgical information to my bill.
A means by which a third-party payer can verify that services billed were actually provided (i.e. insurance company, etc.)
A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.

I understand that my medical information shall not be released to any third-party without a signed authorization bearing my signature with the following exception(s):

Court-ordered subpoena - a binding and legal document issued to custodian of records in a court of law
Emergency medical services whereby the patient's medical records are necessary for the treatment of the patient.

I understand that I have the right:

To object to the use of my health information for directory purposes.
To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations -- and that the organization is not required to agree to the restrictions requested if such restrictions may cause me harm.
To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

10309 SANTA MONICA BLVD, SUITE 300, LOS ANGELES, CALIFORNIA 90025 * TEL. (310)-282-9900 FAX (310) 310-282-8567