For Patients

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.

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

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

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

Please complete and sign the form and return to: Go East Medical Services, P.O. Box 3306, Daly City, CA, 94015, Attention: Health Information Services Manager; 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 GEMS 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)

Go East Medical Services (GEMS) participates in Health Information Exchanges (the “GEMS 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. GEMS patients are automatically enrolled in the GEMS HIE.

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

The goal of the GEMS HIE is to allow your providers outside of GEMS to access the best available information about your health. If you opt-out, your health care providers outside of GEMS 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:

Go East Medical Services
Attention: Grievance Department
P.O. Box 3306
Daly City, CA 94015
(702) 589-9686