Notice of Privacy Practices/HIPAA

This notice describes how protected medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully and sign at the bottom.

1. Pediatricians Inc. is permitted to make uses and disclosures of protected health information (PHI) for treatment, payment, and health care operations, as described in the following examples:

• a. For treatment Providing information to a specialist we've referred to you
• b. For payment Sending or receiving information to/from your health insurance carrier
• c. For healthcare operations review including medical, legal, fraud, and abuse

2. Pediatricians Inc. is permitted or required, under specific circumstances, to use of disclose protected health information (PHI) without the individual's written authorization.

3. Other uses and disclosures will be made only with the individual's written authorization and the individual may revoke such authorization.

4. Pediatricians Inc. intends to engage in (n)one or more of the following activities:

• a. Pediatricians Inc. may contact the individual to provide appointment.

5. The individual has the following rights regarding protected health information (PHI):

• a. The right to request restrictions on certain uses and disclosures of protected health information. Pediatricians Inc. is not required to agree to a requested restriction, however.
• b. The right to receive confidential communications of protected health information, as applicable.
• c. The right to inspect and copy protected health information, as provided in the Privacy Regulation 45 CFR 1664.524.
• d. The right to amend protected health information as provided in the Privacy Regulation 45 CFR 164.528.
• e. The right to receive an accounting of disclosures of protected health information.
• f. The right to obtain a paper copy of this notice from the covered entity upon request. This right extends to an individual who has agreed to receive the notice electronically.

6. Pediatricians Inc. is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information.

7. Pediatricians Inc. is required to abide by the terms of the notice currently in effect.

8. Pediatricians Inc. reserves the right to change the terms of this notice. The new notice provisions will be effective for all protected health information that it maintains and we will provide a copy at next visit after revision.

9. If they believe their privacy rights have been violated, individuals may complain to Pediatricians Incorporated and to the Secretary of the Department of Health and Human Services, without fear retaliation by the organization. A brief description of how the individual may file a complaint follows: in writing, outlining the source, date, & reason.

10. Pediatricians Inc. contact person for matters relating to complaints is: Practice Administrator, Pediatricians Inc., 955 Main Street #103 and #106, Winchester, MA 01890. Phone 781-729-4262, Fax 781-729-0693.

11. This notice is first in effect in April 17, 2021.

12. Pediatricians Inc. elects to limit the uses of disclosures that it is permitted to make as follows: We will not use or disclose your health information without your authorization except as described in this notice.

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.