Notice of Privacy Practices

Effective Date: April 14, 2003

If you have any questions about this notice, please contact the Office’s Privacy Officer.

WHO WILL FOLLOW THIS NOTICE

This notice describes our office’s practices and those of:

• Any healthcare professional authorized to enter information into your child’s medical record.
• Any member of a volunteer group we allow to help your child while in the office.
• All employees, staff and other office personnel.

• All these persons, entities, sites, and locations follow the terms of this notice.  In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or office operations purposes as described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about your child and your child’s health is personal.  We are committed to protecting medical information about your child.  We create a record of the care and services your child receives at the office.  We need this record to provide your child with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your child’s care generated by this office, whether made by office personnel or your child’s doctor. 

This notice will tell you about the ways in which we may use and disclose medical information about your child.  We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies your child is kept private;
• Allow you to read this notice of our legal duties and privacy practices with respect to medical information about your child; and
• Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOUR CHILD

The following categories describe different ways that we use and disclose medical information.  For each category of uses or disclosures we will explain what we mean.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of these categories.

For Treatment.  We may use medical information about your child to provide your child with medical treatment or services.  We may disclose medical information about your child to doctors, nurses, technicians, medical students, or other office personnel who are involved in taking care of your child at the office.  We also may disclose medical information about your child to people outside the office who may be involved in your child medical care after your child leave the office, such as family members, or others to provide services that are part of your child care, such as therapists or physicians.

For Payment.  We may use and disclose medical information about your child so that the treatment and services your child receive at the office may be billed to and payment may be collected from you, an insurance company, or a third party.  For example, we may need to give your child’s health plan information about treatment your child received at the office so your child’s health plan will pay us or reimburse you for the treatment.  We may also tell your child’s health plan about a treatment your child is going to receive to obtain prior approval or to determine whether your child’s plan will cover the treatment.  We also may disclose information about your child to another health care provider, such as another office, for their payment activities concerning your child.

For Healthcare Operations.  We may use and disclose medical information about your child for office operations.  These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care.  For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for your child.  We may also combine medical information about many office patients to decide what additional services the office should offer, what services are not needed, and whether certain new treatments are effective.  We may also disclose information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes.  We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services we offer.  We may remove information that identifies your child from this set of medical information so others may use it to study health care and healthcare delivery without learning the identities of specific patients.  We also may disclose information about your child for another office’s health care operations if your child also has received care at that office.

Treatment Alternatives.  We may use and disclose medical information to tell you about or recommend different ways to treat your child.

Health-Related Benefits and Services.  We may use and disclose medical information to tell you about health-related benefits or services that may be useful to your child.

Individuals Involved in Your child Care or Payment for Your child Care.  We may release medical information about your child to a friend or family member who is involved in your child medical care.  This would include persons named in any durable health care power of attorney or similar document provided to us.  We may also give information to someone who helps pay for your child’s care.  You can object to these releases by telling us that you do not wish any or all individuals involved in your child’s care to receive this information.  If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your child’s best interest to release relevant information to someone who is involved in your child’s care.

Research.  Under certain circumstances, we may use and disclose medical information about your child for research purposes.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information.  Before we use or disclose medical information for research, the project will have been approved through this research approval process.  We may, however, disclose medical information about your child to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the office.  We will almost always ask for your specific permission if the researcher will have access to your child name, address, or other information that reveals who your child is, or will be involved in your child’s care at the office.

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

To Avert a Serious Threat to Health or Safety.  We may use and disclose medical information about your child when necessary to prevent a serious threat to 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 help prevent the threat.

SPECIAL SITUATIONS

Public Health Risks.  We may disclose medical information about your child for public health activities.  These activities generally include the following:

• To prevent or control disease, injury, or disability;
• To report deaths;
• 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; and
• 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 medical 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 healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes.  If your child is involved in a lawsuit or a dispute, we may disclose medical information about your child in response to a court or administrative order.  We may also disclose medical information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

YOUR  RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOUR CHILD

You have the following rights regarding medical information we maintain about your child:

Right to Inspect and Copy.  You have the right to inspect and copy medical information that may be used to make decisions about your child’s care.  Usually, this includes medical and billing records.

To inspect and copy medical information that may be used to make decisions about your child, you must submit your request in writing to the Office’s Privacy Officer.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.  If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy.  Before providing you with such a summary or explanation, we first will obtain your payment of the agreed upon fees, if any, for preparing the summary or explanation.

We may deny your request to inspect and copy your child’s medical information in certain very limited circumstances, such as when your child’s physician determines that for medical reasons this is not advisable.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed healthcare professional chosen by the office will review your request and the denial.  The person conducting the review will not be the person who denied your request.  We will do what this person decides.

Right to Amend.  If you feel that medical information we have about your child is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for the office.

To request an amendment, your request must be made in writing and submitted to the Office’s Privacy Officer.  In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your child request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the office;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information we use or disclose about your child for treatment, payment, or healthcare operations.  You also have the right to request a limitation on the medical information we disclose about your child to someone who is involved in your child’s care or the payment for your child’s care, like a family member or friend.

We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide your child with emergency treatment.

To request restrictions, you must make your request in writing to the Office’s Privacy Officer.  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; and (3) to whom you want the limits to apply, example: grandparents.

Right to Confidential Communications.  You have the right to request to receive communications from us on a confidential basis by using alternative means for receipt of information or by receiving the information at alternative locations.  For example, you can ask that we only contact you at work or by mail, or at another mailing address, besides your home address.  We must accommodate your request, if it is reasonable.  You are not required to provide us with an explanation as to the reason for your request.  Contact the Privacy Officer if you require such confidential communications. This request must also be in writing.

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. 

CHANGES TO THIS NOTICE

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

COMPLAINTS

If you believe your child’s privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services.  To file a complaint with the office, contact Bessie Christopher, Privacy Officer. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with you written permission.  If you provide us permission to use or disclose medical information about your child, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about your child for the reasons covered by you authorization.  You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to your child.

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