4335 N Golden State Blvd. Ste 103
Fresno, CA 93722
(559) 220-3134
https://kfcalifornia.org/kcc
Your Information.
Your Rights.
Our Responsibilities.
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.
You have the right to:
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your
information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have
been violated
You have some choices in the way that we use and
share information as we:
Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds
We may use and share your information as we:
Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement,
and other government requests
Respond to lawsuits and legal actions
Your
Rights
Your
Choices
Our Uses
and
Disclosures
Notice of Privacy Practices | Page 1
Your
Rights
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to
help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information
we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request.
We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us
how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a
different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes”
unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to
the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations,
and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for
free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by
sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Notice of Privacy Practices | Page 2
Your
Choices
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
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and
share your information if we believe it is in your best interest. We may also share your information 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
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
For certain health information, you can tell us your choices about
what we share. If you have a clear preference for how we share your
information in the situations described below, talk to us. Tell us what
you want us to do, and we will follow your instructions.
Our Uses
and
Disclosures
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when
necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How do we typically use or share your health information?
We typically use or share your health information in the following
ways.
Notice of Privacy Practices | Page 3
How else can we use or share your health information?
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. We have to meet many conditions in the law before we can
share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of
Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual
dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective
services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response
to a subpoena.
We do not create or manage a hospital directory.
We do not respond to organ or tissue donation requests.
We will never share any substance abuse treatment records without your written permission.
We will never market or sell your personal information.
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties
Notice of Privacy Practices | Page 4
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. Let us know in
writing if you change your mind.
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 web site.
Effective Date: July 16, 2024
This Notice of Privacy Practices applies to Khalsa Foundation DBA Khalsa Community Center.
Khalsa Foundation DBA Khalsa Community Center
4335 N Golden State Blvd. Ste 103
Fresno, CA 93722
Phone: (559) 220-3134
Email: admin@kfcalifornia.org