PEDIATRIC OTOLARYNGOLOGY HEAD & NECK SURGERY ASSOC., P.A.
NOTICE OF PRIVACY POLICY
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.
The following is the privacy policy of Pediatric Otolaryngology
Head and Neck Surgery Assoc., PA (POHNS) as described in the Health
Insurance Portability and Accountability Act of 1996 and regulations
promulgated thereunder, commonly known as HIPAA. HIPAA requires
POHNS, by law, to maintain the privacy policies with respect to
your child’s personal health information. We are required
by law to abide by the terms of this Privacy Notice.
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.
You have the right to: (a) request that POHNS amend your child’s
protected health information. Please be advised, however, that POHNS
is not required to agree to amend your child’s protected health
information. If your request to amend your child’s health
information has been denied, you will be provided with an explanation
of our denial reason(s) and information about how you can disagree
with the denial; (b) to receive an accounting of disclosures of
your child’s protected health information made by POHNS; and
(c) to a paper copy of this Notice of Privacy Policy at any time
upon request.
Amendments to this Privacy Policy
We reserve the right to amend this Notice of Privacy Policy at
any time in the future, and will make the new provisions effective
for all information that it maintains. Until such amendment is made,
POHNS is required by law to comply with this Notice.
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
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
|
