Acknowledgement of Receipt of Notice of Privacy Practices

3775 45th Ave.
Columbus, NE 68601
402-564-7200
Fax: (402) 564-7210

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

CCH Pediatric Clinic PC is required to maintain the privacy of your health information and to provide you with a notice of its legal duties and privacy practices. We will not use or disclose your health information except as described in this Notice. This Notice applies to all of the medical records generated by CCH Pediatric Clinic PC, as well as records we receive from other providers.

USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION IN TREATMENT, PAYMENT & HEALTH CARE OPERATIONS

Treatment: CCH Pediatric Clinic PC may use and disclose your protected health information in the course of providing or managing your health care as well as any related services. For the purpose of treatment, we may coordinate your health care with a third party. For example, we may disclose your protected health information to a pharmacy to fulfill a prescription for medication, to a radiology facility to order an X-ray, or to another physician who is assisting in your health care. In addition, we may disclose protected health information to other health care providers related to the treatment provided by those other providers.

Payment: When needed, CCH Pediatric Clinic PC will use or disclose your protected health information to obtain payment for its services. Such uses or disclosures may include disclosures to your health insurer to get approval for a recommended procedure or to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. When obtaining payment for your health care, we may also disclose your protected health information to your insurance company to demonstrate the medical necessity of the care or for utilization review when required to do so by your insurance company. Finally, we may also disclose your protected health information to another provider where that provider is involved in your care and requires the information to obtain payment.

Health Care Operations: CCH Pediatric Clinic PC may use or disclose your protected health information when needed for the practice’s health care operations for the purposes of management or administration of the practice and for offering quality health care services. Health care operations may include: (1) quality evaluations and improvement activities; (2) employee review activities and training programs; (3) accreditation, certification, licensing, or credentialing activities; (4) reviews and audits such as compliance reviews, medical reviews, legal services, and maintaining compliance programs; and (5) business management and general administrative activities. For instance, we may use, as needed, protected health information of patients to review their treatment course when making quality assessments regarding care or treatment. In addition, we may disclose your protected health information to another provider or health plan for their health care operations.

Other Uses and Disclosures: As part of treatment, payment, and health care operations, CCH Pediatric Clinic PC may also use or disclose your protected health information to: (1) remind you of an appointment; (2) inform you of potential treatment alternatives or options; or (3) inform you of health-related benefits or services that may be of interest to you.

USES & DISCLOSURES TO WHICH YOU MAY OBJECT

Family/Friends: CCH Pediatric Clinic PC may disclose your protected health information to a friend or family member who is involved in your medical care. For example, we may allow a family member to pick up your x-rays or medical supplies. We may also give information to someone who helps pay for your care. In addition, we may disclose protected health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you have any objection to the use and disclosure of your protected health information in this manner, please tell us.

USES & DISCLOSURES THAT ARE REQUIRED OR PERMITTED WITHOUT YOUR AUTHORIZATION

Research: Under certain circumstances, CCH Pediatric Clinic PC may use and disclose your protected health information for approved clinical research studies. While most clinical research studies require specific patient consent, there are some instances where a retrospective record review with no patient contact may be conducted by such researchers. For example, the research project may involve comparing the health and recovery of patients who received one medication for their medical condition to those who received a different medication for that same condition.

Regulatory Agencies: CCH Pediatric Clinic PC may disclose your protected health information to government and certain private health oversight agencies, e.g., the Nebraska Department of Health and Human Services or the Board of Medical Examiners, for activities authorized by law, including, but not limited to, licensure, certification, audits, investigations and inspections. These activities are necessary to monitor compliance with the requirements of government programs.

Law Enforcement/Litigation: CCH Pediatric Clinic PC may disclose your protected health information for law enforcement purposes as required by law or in response to a court order or other process in litigation.

Public Health: As required by law, CCH Pediatric Clinic PC may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, we are required to report the existence of a communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the Nebraska Department of Health and Human Services, Division of Public Health. In addition, with parent or guardian permission, we may send proof of immunizations to schools.

Workers’ Compensation: CCH Pediatric Clinic PC may release protected health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Military/Veterans: CCH Pediatric Clinic PC may disclose your protected health information as required by military command authorities, if you are a member of the armed forces.

Organ Procurement Organizations: To the extent allowed by law, CCH Pediatric Clinic PC may disclose your protected health information to organ procurement organizations and other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.

As Otherwise Required or Permitted By Law: CCH Pediatric Clinic PC will disclose your protected health information in any situation in which such disclosure is required by law (e.g., child abuse, domestic abuse) or any other use permitted under HIPAA, its amendments or regulations.

Business Associates: CCH Pediatric Clinic PC will disclose your protected health information to our business associates and allow them to create, use and disclose your protected health information to perform their services for us. For example, we may disclose your information to an outside billing company who assists us in billing insurance companies.

Deceased Individuals: We are required to apply safeguards to protect your protected health information for 50 years following your death. Following your death, we may disclose medical information to a coroner, medical examiner, or funeral director as necessary for them to carry out their duties and to a personal representative (for example, the executor of your estate). We may also release your medical information to a family member or other person who acted as personal representative or was involved in your care or payment for your care before death, if relevant to such person's involvement, unless you have expressed a contrary preference.

Threats to Health or Safety: Under certain circumstances, we may use or disclose your protected health information to avert a serious threat to health or safety if we, in good faith, believe the use or disclosure is necessary to prevent or lessen the threat and is to a person reasonably able to prevent or lessen the threat (including the target) or is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.

Specialized Government Functions: We may use and disclose your protected health information for national security and intelligence activities authorized by law or for protective services of the President. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose to the institution, its agents or the law enforcement official your protected health information necessary for your health and the health and safety of other individuals.

Incidental Uses and Disclosures: There are certain incidental uses or disclosures of your information that occur while we are providing services to you or conducting our business. For example, the nurse or doctor may need to use your name to identify you or family members in a waiting area. Other individuals in the waiting area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.

Abuse, Neglect or Domestic Violence: We may notify the appropriate government authority if we believe you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law (for example, to report a particular type of injury), we will only make this disclosure if you agree.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION:

Uses and Disclosures Not Described Above: Other than the circumstances described above, CCH Pediatric Clinic PC will not disclose your protected health information unless you provide written authorization.

Psychotherapy Notes: These are notes made by a mental health professional documenting conversations during private counseling sessions or in joint or group therapy. Many uses or disclosures of psychotherapy notes require your authorization.

Marketing: We will not use or disclose your protected health information for marketing purposes without your authorization. Moreover, if we receive any financial remuneration from a third party in connection with marketing, we will tell you that in the authorization form.

Sale of Protected Health Information: We will not sell your protected health information to third parties without your authorization. Any such authorization will state that we will receive remuneration in the transaction.

If you provide authorization, you may revoke it at any time by giving us notice in accordance with our authorization policy and the instructions in our authorization form. Your revocation will not be effective for uses and disclosures made in reliance on your prior authorization.

YOUR RIGHTS RELATED TO YOUR HEALTH INFORMATION:

Although all records concerning your treatment obtained at CCH Pediatric Clinic PC are the property of CCH Pediatric Clinic PC, you have the following rights concerning your protected health information:

• Right to Confidential Communications: You have the right to receive confidential communications of your protected health information by alternative means or at alternative locations. For example, you may request that we contact you at work or by mail.
• Right to Access Protected Health Information: You generally have the right to inspect and copy your protected health information, except as restricted by your physician or by law. Further, if we maintain your health records on an electronic health records system, you have the right to request an electronic copy of your health records. If we cannot readily produce the record in the form and format you request, we will produce it in another readable electronic form we both agree to. We may charge a cost-based fee for producing copies or, if you request one, a summary. If you direct us to transmit your medical information to another person, we will do so, provided your signed, written direction clearly designates the recipient and location for delivery.
• Right to Amend: You have the right to request an amendment or correction to your protected health information. If we agree that an amendment or correction is appropriate, we will ensure that the amendment or correction is attached to your medical record.
• Right to an Accounting: You have the right to obtain a statement of the disclosures that have been made of your protected health information other than by your authorization, other than to you and other than for the purpose of treatment, payment or health care operations purposes.
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your protected health information. If we agree, we will abide by the restrictions. Additionally, if you (or anyone on your behalf besides a health plan) pay for the care or services at issue in full out of your own pocket, we are required to comply with your request not to disclose your protected health information to a health plan, unless required by law to do so.
• Right to Receive a Copy of this Notice: You have the right to receive a paper copy of this Notice, upon request, if this Notice has been provided to you electronically.
• Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your protected health information, except to the extent that action has already been taken in reliance on your authorization.
• Right to Notice of Breach of Security: You have the right to be notified in the event of a breach of unsecured protected health information occurs.
• Right to Opt Out: You may be contacted for certain fund-raising purposes and you have the right to opt out of receiving such communications.

FOR MORE INFORMATION REGARDING HOW TO EXERCISE THESE RIGHTS: If you have questions or would like more information regarding any of the rights listed above, please contact the Administrator at (402) 564-7200

IF YOU BELIEVE THAT YOUR RIGHTS HAVE BEEN VIOLATED: You may file a complaint with CCH Pediatric Clinic PC or with the U.S. Secretary of Health and Human Services. To file a complaint with CCH Pediatric Clinic PC please contact the Administrator at (402) 564-7200. All complaints must be submitted in writing. There will be no retaliation for filing a complaint.

NOTICE EFFECTIVE DATE: 1-1-2020

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of CCH Pediatric Clinic P.C.'s Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.