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originally effective April 14, 2003
THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOUR CHILD OR OTHER MEMBERS OF
YOUR FAMILY MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN
THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
A federal regulation, known as the HIPAA Privacy Rule,
requires that we provide detailed notice in writing of our
privacy practices. We apologize for the length of this
notice but the HIPAA Privacy Rule requires us to address
many issues in this notice.
I. Our commitment to protecting
health information about your child, you, and your
family.
-- HIPAA Privacy Rule requires that we protect
health information which identifies a patient or family,
information which is called Protected Health Information or
PHI.
-- we will maintain the privacy of all PHI.
-- we give you this notice of our legal duties and privacy
practices.
-- we reserve the right to change this notice in accordance
with current law, and post a copy of such changes in our
office in a prominent location, and provide you with a copy
of the revised notice upon your request.
II. How we may use and disclose
Protected Health Information (PHI) without your written
authorization or opportunity to agree or object.
-- for treatment: We may use and disclose PHI
to provide, coordinate, and manage your child's health care
and related services. Examples include disclosure of PHI
when your child requires referral to another physician,
health care professional, or hospital, a prescription drug
or device, laboratory tests, imaging tests, or other
specialized testing or therapy.
-- for payment: We may use and disclose PHI in order to
verify your coverage for particular treatment and services
and to collect payment for your child's treatment and other
services from third party payers including your health plan,
their paid reviewers, and other insurance companies
providing you with additional coverage.
-- for health care operations: We may use and disclose PHI
in order to help improve the quality of your child's care
and reduce its cost. This includes providing training to
other health care providers, cooperating with outside
organizations which certify the quality of providers or
institutions, providing information to professionals who
help us improve and maintain the quality and efficiency of
the services we provide to you child and to others,
resolving grievances which occur within our practice, and
converting PHI to de-identified health information, data
which cannot be associated with your child or with other
members of your family.
-- for communication from our office to you: We may use and
disclose PHI to remind you of appointments and to provide
you with information about alternative therapies.
-- for involvement of non-family members in your child's
care: We may use and disclose PHI to enlist the help in your
child's care of your family member, close friend, or any
other person identified by you. In these situations, we will
use your direct instructions as well as our best
professional judgements to make reasonable decisions about
your child's best interests in allowing someone other than a
parent to act on the behalf of your child to perform such
functions as picking up and delivering prescriptions,
x-rays, medical supplies or other items which contain direct
or indirect PHI about your child and family.
-- for compliance with law: We may use and disclose PHI to
comply with applicable federal, state, or local laws
including worker's compensation and Medicare laws.
-- for compliance with public health directives: We may use
and disclose PHI to assist public health and other
authorities in their efforts to prevent or control
communicable diseases, general or school-based injuries,
disabilities, and injuries or complications from
FDA-regulated medications or devices.
-- for prevention and control of abuse, neglect, or domestic
violence: We may use and disclose PHI to properly
constituted government authorities if we reasonably believe
that a patient has been a victim of domestic violence,
abuse, or neglect.
-- for health oversight activities: We may use and disclose
PHI to a health oversight agency for audits, investigations,
inspections, licensure and disciplinary activities, and
other activities necessary to monitor the health care system
including government health care programs.
-- for support of legal proceedings: We may use and disclose
PHI when ordered by a court order, subpoena, or discovery
requests.
-- for support of law enforcement: We may use and disclose
PHI to law enforcement authorities if the patient is a
suspected crime victim, if law enforcement authorities
indicate that it is necessary to locate a suspect, fugitive,
material witness, or a missing person, if it relates to a
crime or suspected crime committed in this office, if it is
in response to a medical emergency not occurring in the
office, and if it is necessary to report a crime and its
nature, location, and the identity of those who committed
the crime.
-- for post-mortem matters: We may use and disclose PHI to a
coroner or medical examiner and, if authorized by law, a
funeral director, to allow them to carry out their jobs.
-- for selected research activities allowed or required by
the HIPAA Privacy Act: We may use and disclose PHI to
governmental agencies for certain research or oversight of
our practice and others and to you should you desire it.
-- for prevention of a serious threat to health or safety:
We may use and disclose PHI to an appropriate person about
your child or family in limited circumstances to prevent a
threat to the health or safety of another person or to the
public.
-- for support of certain specialized government activities:
We may use and disclose PHI to support certain activities
including military maneuvers, executive protection, national
security, intelligence gathering, and protection of the
health of persons in custody.
ALL OTHER USES AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION REQUIRE YOUR WRITTEN
AUTHORIZATION. AT ANY TIME, YOU MAY REVOKE YOUR
AUTHORIZATION, BUT ACTIONS TAKEN PRIOR TO YOUR REVOCATION
WILL STAND.
III. Your rights regarding Protected Health Information
about your child and family.
-- right to request restrictions: You have the
right to request restrictions on the PHI that we may use for
treatment, payment, and health care operations. To request
restrictions, you must make your request in writing to our
Privacy Officer using the request form we provide. We are
not required to comply with your request if we feel that it
is in violation of the above-noted legal directives. In such
a case, we will provide you with a written notice of
denial.
-- right to receive confidential communications: You have
the right to request that you receive communications
containing PHI in a certain manner or at a certain location.
You must make your request in writing to our Privacy Officer
specifying how and where you would like to be contacted. We
are required to accommodate reasonable requests.
-- right to inspect and copy: You have the right to copy or
inspect PHI about you. This does not include PHI gathered
for a civil, criminal, or administrative proceeding. We may
deny your request only in limited circumstances. You must
make your requests to inspect and copy in writing to our
Privacy Officer, and we may charge you a reasonable fee for
copying, postage, labor, and supplies used to meet your
request.
-- right to amend: You have the right to amend your PHI
about your child or family as long as such information is
kept by or for our office. This request must be made in
writing to our Privacy Officer, and you must include a
reason for the request.
-- right to receive an accounting of disclosures: You have
the right to request an accounting of certain disclosures of
your PHI. This request, in writing to our Privacy Officer,
must be for a list of disclosures other than those specified
in Section I above made during a time period up to six
years.
IV. Complaints
If you believe your privacy rights have been
violated, you may file a complaint with us or with the
Secretary of the U.S. Department of Health and Human
Services. To file a complaint with us, please contact our
Privacy Officer. We will not retaliate or take action
against you for filing a complaint.
IV. Privacy Officer Contact
Information
You may contact our Privacy Officer Judy Smith
at the address and phone number below.
This notice was published and first became effective on
April 14, 2003.
© 2010 Howard G.
Smith MD
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Thank
you for reviewing this HIPAA privacy notice. It
is part of the federal law that you sign a form
acknowledging that you have read and accept
these privacy rules and that you consent to
their application. Please click on the following
link to reach the form which you may print,
sign, and either bring in at your child’s
next visit or fax to our office:
Acknowledgement
and Consent
Form
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