THIS NOTICE DESCRIBES HOW INFORMATION ABOUT PATIENTS MAY BE USED AND DISCLOSED AND HOW PATIENTS CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Pediatric Center is committed to treating and using personal health information about all our patients responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes patient rights as they relate to personal health information. This applies to all personal health information as defined by federal regulations.
Understanding Health Records/Information
Each time a patient visits or calls The Pediatric Center, a record of the visit/call is made. Typically, this record contains symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as the health or medical record, can possibly serve as a:
*Basis for planning care and treatment,
*Means of communication among the many health professionals who contribute to the care,
*Legal document describing the care received,
*Means by which you or a third-party payer can verify that services billed were actually provided,
A tool in educating health professionals,
A source of data for medical research,
A source of information for public health officials charged with improving the health of this state and the nation,
A source of data for our planning and marketing,
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve,
*most likely uses of personal health information at The Pediatric Center.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of The Pediatric Center, the information belongs to you. You have the right to:
Obtain a paper copy of this notice of information practices upon request
Inspect and copy the health record (a reasonable fee may be required),
Request an amendment of the health record
Obtain an list of the disclosures of the health information
Request a restriction on certain uses and disclosures of your information and
Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
The Pediatric Center is required to:
Maintain the privacy of the health information,
Provide patients with this notice as to our legal duties and privacy practices with respect to information we collect and maintain,
Abide by the terms of this notice,
Notify the patients if we are unable to agree to a requested restriction, and
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide the updated policy at the time of a future visit as well as keep the current policy on our website – www.thepediatriccenter.net.
We will not use or disclose health information without authorization, except as described in this notice. We will also discontinue to use or disclose health information after we have received a written revocation of the authorization.
We will provide health information without authorization when necessary for treatment, payment or healthcare operations.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Appointment Notification: We may contact you to provide appointment reminders and suggest follow-up/additional treatment in our office. Appointment reminders may be provided by postcard.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: As required by law, we may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. For example, vaccine reactions are reported to governmental agencies as required by law.
Correctional institution: Should a patient eventually become an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for healthcare and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. (eg. child protection, etc)
Federal law makes provision for health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
I have received and read the Notice of Health Information Practices. I fully understand the Notice and have had all my questions answered.
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.
For More Information or to Report a Problem
If you want additional information or if you believe your privacy rights have been violated, you can contact The Pediatric Center’s Privacy Officer, or the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
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