PEDIATRIC OTOLARYNGOLOGY HEAD & NECK SURGERY ASSOC., P.A.
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your Child’s Personal Health Information
We collect your child’s personal health information from you through treatment, payment and related healthcare operations, the application and enrollment process, and/or healthcare providers or health plans, or through other means, as applicable. Your child’s personal health information that is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain healthcare entities, including healthcare providers, such as physicians and hospitals, as well as, health insurance companies or plans. The law specifically protects health information that contains data, such as your child’s name, address, social security number, and others, that could be used to identify your child as the individual patient who is associated with that health information.
Disclosure of Your Child’s Personal Health Information
Generally, we may not use or disclose your child’s personal health information without your permission. Further, once your permission has been obtained, we must use or disclose your child’s personal health information in accordance with the specific terms of that permission. The following are the circumstances under which we are permitted by law to use or disclose your child’s personal health information.
Without Your Consent
Without your consent, we may use or disclose your child’s personal health information in order to provide him/her with the services and the treatment he/she requires or requests, or to collect payment for those services, and to conduct other related health care operations otherwise permitted or required by law.
Examples of treatment activities include: (a) the provision, coordination, or management of healthcare and related services by healthcare providers; (b) consultation between healthcare providers relating to a patient; or (c) the referral of a patient for healthcare from one healthcare provider to another.
Examples of payment activities include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.
Examples of healthcare operations include: (a) development of clinical guidelines; (b) contacting patient’s parents/legal guardians with information about treatment alternatives or communications in connection with case management or care coordination; and (c) medical review, legal services, and auditing functions.
As Required by Law
We may use or disclose your child’s personal health information to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law. Examples include: (a) to notify or assist in notifying the parent, legal guardian or family member or another person responsible for your child’s care about his/her medical condition or in the event of an emergency or death; (b) to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure; (c) to judicial and administrative proceedings in the course of any legal proceeding; (d) to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes; (e) to coroners or medical examiners; (f) to researchers conducting research that has been approved by an Institutional Review Board; (g) to avert a serious threat to health or safety; and (h) to provide you with appointment reminders for your child, or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Miscellaneous Activities, Notice: In the event that POHNS is sold or merged with another organization, your child’s health information/record will become the property of the new owner.
Your Rights with Respect to Your Child’s Personal Health Information
Under HIPAA, you have certain rights with respect to your child’s personal health information. The following is a brief overview of your rights and our duties with respect to enforcing those rights.
Your have the right: (a) to request restrictions on certain uses and disclosures of your child’s health information. (Please be advised, however, that POHNS is not required to agree to the restriction that you requested); (b) to have your child’s health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request; (c) to have the right of access in order to inspect and obtain a copy of your child’s health information contained in your child’s designated record, except for (1) psychotherapy notes, (2) information complied in reasonable anticipation of, or for use in a civil, criminal, or administrative action or proceeding, and (3) health information maintained by us to the extent to which the provision of access to you would be prohibited by law. We will require written requests.
POHNS is required by law to maintain the privacy of your child’s health information and to provide you with notice of its legal duties and privacy policies with respect to your child’s health information. If you have questions or complaints about any part of this notice, or if you want more information about your privacy rights, please contact the Administrator of POHNS by calling this office at (727) 892-4305. If he/she is not available, you may make an appointment for a personal conference in person or by telephone within two (2) working days.
Complaints about your privacy rights, or how POHNS has handled your child’s health information should be directed to the Administrator at (727) 892-4305. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509 F HHH Building
Washington, DC 20201
I have read the Privacy Notice and understand my rights contained in the notice.
By way of my signature, I provide POHNS with my authorization and consent to use and disclose my child’s protected healthcare information for the purposes of treatment, payment and healthcare operations as described in the Privacy Notice.
Patient’s Name (please print)
Parent/Legal Guardian Name (please print) Date
Parent/Legal Guardian Signature Date
Authorized Facility Signature Date