NOTICE OF PRIVACY PRACTICES

Effective 04/13/03 (Revised 03/20/03)

 This notice describes how your/your child’s health information may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact our Privacy Officer.

Our Commitment to Your/Your Child’s Privacy

We are committed to protecting health information about you/your child. We create a record of the care and services you/your child receive from us in order to provide you/your child with quality care and to comply with certain legal requirements. This notice informs you of the ways in which we may use and disclose identifiable health information about you/your child. We also describe your rights and certain obligations we have regarding the use and disclosure of health information.

We are required by law to:
Maintain the confidentiality of health information that identifies you/your child; provide you with this notice of our legal duties and privacy practices concerning your/your child’s identifiable health information; and follow the terms of our notice that is currently in effect.

How We May Use and Disclose Your/Your Child’s Health Information

The following categories describe the different ways in which we may use and disclose your/your child’s identifiable health information:

Treatment. We may use health information about you/your child to provide you/your child with health treatment or services. We may disclose health information about you/your child to our doctors, nurses, technicians, or other personnel who are involved in taking care of you/your child or who are arranging for care. We also may disclose health information about you/your child to people outside our practice who may be involved in your/your child’s health care, such as other doctors or hospital employees providing services that are part of your/your child’s care.

Payment. We may use and disclose health information about you/your child so that the treatment and services you/your child receives from us may be billed and payment may be collected from you, an insurance company, or a third party. For example, we may need to provide your health insurer with information about treatment you/your child received from us so your insurer will pay us or reimburse you for surgery. We may also tell your health insurer about a treatment you/your child is going to receive to obtain prior approval or to determine whether your insurer will cover the treatment.

Health Care Operations. We may use and disclose health information about you/your child for our practice’s operations. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use your/your child’s health information to evaluate our performance in caring for you/your child.

Appointment Reminders. We may use and disclose health information about you/your child to contact you and remind you of an appointment with us.

Treatment Alternatives. We may use and disclose your/your child’s health information to tell you about or recommend possible treatment options or alternatives.

Health Related Benefits and Services. We may use and disclose your/your child’s health information to tell you about health-related benefits or services.

Individuals Involved in Your/Your Child’s Care or Payment for Your/Your Child’s Care. With your permission, we may release health information about you/your child to a friend or family member who is involved in your/your child’s health care. We may also give information to someone who helps pay for your/your child’s care.

Research. Under certain circumstances, we may use and disclose health information about you/your child for research purposes. All research projects, however, are subject to a special approval process. Before we use or disclose health information for research, the project will have been approved through a research approval process, but we may, however, disclose health information about you/your child to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave our offices. We will attempt to obtain your specific permission if the researcher will have access to your name, address or other information that reveals you/your child.

As Required by Law. We will disclose health information about you/your child when required to do so by federal, state or local law.

Serious Threats to Health or Safety. We may use and disclose health information about you/your child when necessary to prevent a serious threat to your/your child’s health and safety or the health and safety of the public or another person Any disclosure, however, would only be to someone able to prevent the threat.

Organ and Tissue Donation. If you are/your child is an organ donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military. If you become/your child becomes a member of the armed forces, we may release health information about you/your child as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Worker’s Compensation. We may release health information about you/your child for worker’s compensation or similar programs.

Public Health Risks. We may disclose health information about you/your child for public health activities. These activities generally include, but are not limited to, the following:
To prevent or control disease, injury or disability;
To report births and deaths;
To report child abuse or neglect;
To report reactions to medications or problems with products;
To notify people of recalls of products they may be using;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition:
To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care systems, government programs and compliance with civil rights laws.

Lawsuits or Similar Proceeding. If you are involved in a lawsuit or a similar proceeding, we may disclose your/your child’s health information in response to a court or administrative order. We may also disclose your/your child’s health information in response to a subpoena, discovery requests or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release health Information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness or missing person;
About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
About criminal conduct at our offices; and
In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Effective 04/13/03 Revised 03/20/03

Deceased Patients. We may release health information to a coroner or medical examiner to identify a deceased person or determine the cause of death, and to funeral directors as necessary to carry out their duties.

National Security. We may release health information about you/your child to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. We may also disclose health information about you/your child to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are/your child is an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you/your child to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you/your child with health care; (2) to protect your/your child’s health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Your Rights Regarding Your/Your Child’s Health Information

You have the following rights regarding the your health information of your child’s health information until they reach the age of majority:

Inspection and Copies. You have the right to inspect and obtain a copy of your/your child’s health information that may be used to make decisions about your/your child’s care. This typically includes health and filing records, but does not include psychotherapy notes. To inspect and/or obtain a copy of your/your child’s health information, you must submit your request in writing to us. We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.

Reviews will be conducted by another licensed health care professional chosen by us.

Amendment. You may ask us to amend your/your child’s health information if you believe it is incorrect or incomplete, and may request an amendment for as long as the information is kept by and for our practice. To request an amendment, your request must be made in writing and submitted to us. You must provide us with a reason that supports your requests for amendment. Your failure to submit your request (and the reason supporting your request) in writing will result in our denying your request.

Your requests also may be denied if we are asked to amend information:

Not created by us, unless the person or entity that created the information is no longer available to make the amendment; Not part of the health information kept by or for the practice; Not part of the information which you would be permitted to inspect and copy; Or that is accurate and complete.

Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a list of certain disclosures we have made of your/your child’s health information.

To request this list or accounting of disclosures, you must submit your request in writing to us. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free, but we may charge you for additional lists. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction on our use or disclosure of your/your child’s health information for treatment, payment or health care operations. You also have the right to request that we limit the health information we disclose about you/your child to someone who is involved in your child’s care or the payment of your/your child’s care, like a family member or friend. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except in cases of emergency, when otherwise required by law, or when the information is necessary to provide treatment to your/your child. To request restrictions, you must make your request in writing to us. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; (3) to whom you want the limits to apply.

Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work. To request confidential communications, you must make your request in writing to us. We will not ask you the reason for your request and we will accommodate reasonable requests; however, your written request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of the notice, contact our office.

We Reserve the Right to Revise Our Privacy Notice

We reserve the right to change this notice. We reserve the right to make the revised notice effective for health information we already have about you/your child as well as any information we receive in the future. We will post a copy of the current notice in our offices. The notice will contain, on the first page, in the top right-hand corner, the effective date.

Complaints

If you believe your/your child’s privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, contact our Privacy Officer. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Health Information

Other uses and disclosure of health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose health information about you/your child, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you/your child for the reasons covered by your written authorization We are unable to “undo” or take back any disclosures we have already made with your permission. Please note, we are required to retain records of your/your child’s care.