Roswell Pediatric Center, P.C. Notice Of Privacy Practices
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR CHILD (AS A PATIENT OF THIS PRACTICE ) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR CHILD’S INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY

A. OUR COMMITMENT TO YOUR CHILD’S PRIVACY
Our practice is dedicated to maintaining the privacy of your child’s individually identifiable health information (IIHI). In conducting our business, we will create records regarding your child and the treatment and services we provide. We are required by law to maintain the confidentiality of health information that identifies your child. We also are required by law to provide your child’s guardian with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child’s IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide to you, as your child’s guardian the following important information:
· How we may use and disclose your child’s IIHI
· Your child’s privacy rights in their IIHI
· Our obligations concerning the use and disclosure of your child’s IIHI
The terms of this notice apply to all records containing your child’s IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your child’s records that our practice has created or maintained in the past, and for any of your child’s records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and as your child’s guardian you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Roswell Pediatric Center, P.C.
Privacy Official
3400-C Old Milton Pkwy #545
Alpharetta, GA 30005
770-751-0800

C. WE MAY USE AND DISCLOSE YOUR CHILD’S INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
1. Treatment. Our practice may use your child’s IIHI to treat your child. For example, we may ask your child to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your child’s IIHI in order to write a prescription for your child, or we might disclose your child’s IIHI to a pharmacy when we order a prescription for your child. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your child’s IIHI in order to treat your child or to assist others in your child’s treatment. Additionally, we may disclose your child’s IIHI to others who may assist in your child’s care, such as your spouse, or parents. Finally, we may also disclose your child’s IIHI to other health care providers for purposes related to your child’s treatment, such as immunization records, and referral authorization.
2. Payment. Our practice may use and disclose your child’s IIHI in order to bill and collect payment for the services and items your child may receive from us. For example, we may contact your child’s health insurer to certify that your child is eligible for benefits (and for what range of benefits), and we may provide your child’s insurer with details regarding your child’s treatment to determine if your child’s insurer will cover, or pay for, your child’s treatment. We also may use and disclose your child’s IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your child’s IIHI to bill you directly for services and items. We may disclose your child’s IIHI to other health care providers and entities to assist in their billing and collection efforts.
3. Health Care Operations. Our practice may use and disclose your child’s IIHI to operate our business. As examples of the ways in which we may use and disclose your child’s information for our operations, our practice may use your child’s IIHI to evaluate the quality of care your child received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your child’s IIHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our practice may use and disclose your child’s IIHI to contact you and remind you of your child’s appointment.
5. Treatment Options. Our practice may use and disclose your child’s IIHI to inform you of potential treatment options or alternatives available to your child.
6. Health-Related Benefits. Our practice may use and disclose your child’s IIHI to inform you of health-related benefits or services that may be of interest to your child.
7. Release of Information to Family/Friends. Our practice may release your child’s IIHI to a friend or family member that is involved in your child’s care, or who assists in taking care of your child. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
8. Disclosures Required By Law. Our practice will use and disclose your child’s IIHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR CHILD’S IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
1. Public Health Risks. Our practice may disclose your child’s IIHI to public health authorities that are authorized by law to collect information for the purpose of:
· maintaining vital records, such as births and deaths
· maintaining and reporting immunization records
· reporting child abuse or neglect
· preventing or controlling disease, injury or disability
· notifying a person regarding potential exposure to a communicable disease
· notifying a person regarding a potential risk for spreading or contracting a disease or condition
· reporting reactions to drugs or problems with products or devices
· notifying individuals if a product or device they may be using has been recalled
· notifying appropriate government agency and authority regarding the potential abuse or neglect of an adult or child patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
· notifying your child’s employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose your child’s IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your child’s IIHI in response to a court or administrative order, if you or your child are involved in a lawsuit or similar proceeding. We also may disclose your child’s IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
· Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
· Concerning a death we believe has resulted from criminal conduct
· Regarding criminal conduct at our offices
· In response to a warrant, summons, court order, subpoena or similar legal process
· To identify/locate a suspect, material witness, fugitive or missing person
· In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
6. Organ and Tissue Donation. Our practice may release your child’s IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if your child is an organ donor.
7. Research. Our practice may use and disclose your child’s IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your child’s IIHI for research purposes.
8. Serious Threats to Health or Safety. Our practice may use and disclose your child’s IIHI when necessary to reduce or prevent a serious threat to your child’s health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
9. Military. Our practice may disclose your child’s IIHI if your child is a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your child’s IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your child’s IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your child’s IIHI to correctional institutions or law enforcement officials if your child is an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to your child, (b) for the safety and security of the institution, and/or (c) to protect your child’s health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release your child’s IIHI for workers’ compensation and similar programs.

E. YOUR CHILD’S RIGHTS REGARDING THEIR IIHI
1. Restricting Communications. As your child’s guardian you have the right to request that our practice restrict communications in certain situations. For example, in custody and/or other legal situations, parents might request a restriction of communications with certain individuals. In order to request the restriction, you must submit the request in writing to our Privacy Official. Our practice will accommodate reasonable requests. Forms are available at the front desk.
2. Requesting Restrictions of Your Child’s IIHI. As your child’s guardian you have the right to request a restriction in our use or disclosure of your child’s IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your child’s IIHI to only certain individuals involved in your child’s care or the payment for your child’s care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat your child. In order to request a restriction in our use or disclosure of your child’s IIHI, you must submit your request in writing to our Privacy Official. Forms are available at the front desk. Your request must describe in a clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) to whom you want the limits to apply.
3. Inspection and Copies. As your child’s guardian you have the right to obtain a copy and inspect the IIHI that may be used to make decisions about your child, including patient medical records, billing records, and an accounting of disclosures of your child’s IIHI, but not including psychotherapy notes. An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your child’s IIHI for non-treatment, non-payment or non-operations purposes. Use of your child’s IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your child’s information to file your child’s insurance claim. In order to obtain a copy of your child’s records, you must submit your request in writing to a front desk employee. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and copy in certain limited circumstances; however, you may request a review of our denial. Forms are available at the front desk.
4. Amendment. As your child’s guardian you may ask us to amend your child’s health information if you believe it is incorrect or incomplete. To request an amendment, your request must be submitted in writing to our Privacy Official. You must provide us with a reason that supports your request for amendment. We may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. Forms are available at the front desk.
5. Right to a Paper Copy of This Notice. As your child’s guardian you are entitled to receive a paper copy of our notice of privacy practices. To obtain a paper copy of this notice, ask a front desk employee or submit a written request to our Privacy Official, or on our website: www.roswellpediatrics.com.
6. Right to File a Complaint. As your child’s guardian, if you believe your child’s privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, submit your complaint in writing to our Privacy Official. Your child will not be penalized for filing a complaint. Forms are available at the front desk.
7. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your child’s IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your child’s IIHI for the reasons described in the authorization. Temporary Medical Guardianship: We have a form available at the front desk for guardians to fill out to give temporary permission to person(s) responsible for their children’s care during their absence.
Again, if you have any questions regarding this notice or our health information privacy policies, please contact our Privacy Official at 770-751-0800.

Effective April 1, 2003

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