This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review the Notice of Privacy Practices carefully.

• Notice of Privacy Practices – English
• Notice of Privacy Practices – Chinese

Completion of this document authorizes the use or disclosure of health information about you.

• Authorization to Disclose Health Information (English)
• Authorization to Disclose Health Information (Chinese)

Please complete and sign the form and return to: North East Medical Services, Attention: Health Information Services Manager, 2171 Junipero Serra Blvd, Daly City, CA, 94015; or email the form to [email protected].

Please note that email messages may not be encrypted or secure and could be intercepted, viewed, copied, or shared by an unauthorized third party. If you choose to email us, you acknowledge that NEMS has warned you of the risks and you knowingly assume such risks.

You have the right to request restrictions on how we use and disclose your PHI for treatment, payment, and health care operations. All requests must be made in writing.

• Request for a Restriction on Use or Disclosure of Protected Health Information (English)
• Request for a Restriction on Use or Disclosure of Protected Health Information (Chinese)

You have the right to request that we provide your PHI to you in a confidential manner. For example, you may request that we send your PHI by an alternate means (e.g., sending by a sealed envelope, rather than a post card) or to an alternate address (e.g., calling you at a different telephone number, or sending a letter to you at your office address rather than your home address). We will accommodate any reasonable request, unless it is administratively too burdensome, or prohibited by law.

• Right to Confidential Communications by Alternative Means or Alternate Location (English)
• Right to Confidential Communications by Alternative Means or Alternate Location (Chinese)

You have the right to request amendments to your PHI for so long as the information is maintained in our medical and billing records. If you wish to have your PHI corrected or updated, please write to us and tell us what you want changed and why.

• Medical Record Request for Correction/Amendment (English)
• Medical Record Request for Correction/Amendment (Chinese)

North East Medical Services (NEMS) participates in Health Information Exchanges (the “NEMS HIE”). A Health Information Exchange allow doctors, nurses, pharmacists, and other health care providers to securely share your health information electronically and allows providers to have the most recent information to care for you as a patient. NEMS patients are automatically enrolled in the NEMS HIE.

You have the right to opt-out if you do not want NEMS to share your health information through the NEMS HIE. This will not affect your ability to access any health care or medical services.

The goal of the NEMS HIE is to allow your providers outside of NEMS to access the best available information about your health. If you opt-out, your health care providers outside of NEMS may have less information about you when making a diagnosis or decisions about your care.

• Health Information Exchange (HIE) Patient Opt-Out Form (English/Chinese)

To file a complaint or grievance, please download and complete a form:

• Patient Complaint/Grievance Form (English)
• Patient Complaint/Grievance Form (English/Chinese)

Please return this form to or call for assistance:

North East Medical Services – Las Vegas
Attention: Grievance Department
2171 Junipero Serra Blvd.
Daly City, CA 94014
(702) 589-9686