San Francisco Department of Public Health
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(Rev. 11/02/22) SFDPH Office of Compliance and Privacy Affairs
SFDPH Summary Notice of HIPAA Privacy Practices and Acknowledgement of Receipt
Full Notice: You have been provided the Full Notice of HIPAA Privacy Practices. Please read it carefully. You can
also find it at: https://www.sfdph.org.
Who will follow the rules in this notice: All DPH and contract provider employees, DPH affiliates including staff
assigned to DPH by the University of California at San Francisco, and anyone allowed to read, use or give out
patients’ personal health information must follow these rules.
You have the right to: (Please see possible restrictions in the “Full Notice of Privacy Practices”.)
• Request and receive a paper copy of the Full Notice of Privacy Practices
• Ask to see, read and/or obtain a copy of your health record (charges may be necessary).
• Ask to change information that you believe is wrong in your health record.
• Ask that your health information not be shared with certain individuals.
• Ask that your health information not be used for certain purposes; for example, research.
• Ask that copies of your health record be sent to someone (charges may be necessary).
• Be informed about who has read your record (for reasons other than treatment, payment and operations).
• Specify where and how DPH employees may contact you.
DPH may use and disclose your health information to improve your treatment.
• To improve the quality of care you receive, health information may be shared between treatment providers
both within and outside of DPH.
• There are circumstances when health information about you will not be shared unless you first give your
permission for it to be shared.
If you believe your privacy rights have NOT been maintained while receiving DPH services, you may file a
complaint. If you have concerns about how your health information might be (or has been) shared, please speak
with your provider or contact either of the following: (1) DPH Office of Compliance and Privacy Affairs, 101
Grove St., Room 400, San Francisco, CA 94102 or call toll-free 1-855-729-6040. (2) Write Centralized Case
Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W.,
Room 509F HHH Bldg. Washington, D.C. 20201. See “Where to file a privacy complaint with the federal
government” in full notice. You will not be penalized in any way for filing a complaint.
I acknowledge receipt of the SF Department of Public Health “Full Notice of HIPAA Privacy Practices.”
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