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PARTNERS IN PEDIATRICS
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
Who Will Follow This Notice
Partners in Pediatrics, Suffern, Monroe, NY These sites, and locations follow the terms of this notice and may share health information with each other for treatment, payment, or health care operations purposes described in this notice.
Our Pledge Regarding Health Information
The privacy of your medical information is important to us and we are committed to protecting
health information about you. This notice applies to all of the records of your care generated or
received by doctors and staff of this health care practice. This notice will tell you about the ways in
which we may use and disclose health information about you. We also describe your rights to the
health information we keep about you, and certain obligations we have regarding the use and
disclosure of your health information. As appropriate, the terms “you” and “your” refer to the
parents’, custodial parents’ or legal guardian’s minor child/children. We are required by law to:
• Make sure that health information that identifies you is kept private;
• . Give you this notice of our legal obligations and privacy practices
• Follow the terms of the notice that is currently in effect.
How We May Use And Disclose Health Information About You For Treatment Payment And Health
FOR TREATMENT.We may use and disclose your personal health information to provide you with
health care treatment and services and to coordinate your care and treatment with other health care
providers. We may disclose and share health information about you to doctors, nurses, therapists,
technicians, or other providers to assist them in treating you. For example, we may disclose your
health information to a pharmacist who needs that information to fill a prescription ordered by your
doctor. We may also disclose your health information to a doctor to whom you have been referred
to ensure that the doctor has the necessary information to treat you.
FOR PA YMENT:We may use and disclose health information about you to obtain payment for the
treatment and services you receive from us. For example, we may contact your health plan for
coverage or give them information about your office visit so your health plan will pay us or
reimburse you for the visit.
FOR HEALTH CARE OPERATIONS:We may use and disclose your health information for operations
of our health care practice. These uses and disclosures are necessary to run our practice and make
sure that all of our patients receive quality care. For example, we may use health information for
training and education purposes, to review our treatment and services and to evaluate the
performance of our staff in caring for you. We may also combine health information about many
patients to decide what additional services we should offer, or whether certain new treatments are
We May Use And Disclose Your Health Information For Other Purposes Without Your Authorization
APPOINTMENT REMINDERS AND TEST RESULTS: Unless you object, we will as necessary, inform
you by telephone of test results. We may use or disclose health information to remind you about
appointments. Please let us know if you do not wish to have us contact you concerning an
appointment, or if you wish to be contacted by a different telephone number or address for this
NOTIFICATION. In case of emergency, and you are not able to give or refuse permission, we will
share health information according to our professional judgment that is in your best interest. We
will share only the health information directly needed for your care and limited to information
related to the person’s involvement in your care.
HEALTH-RELATED SERVICES AND TREATMENT ALTERNATIVES: We may use or disclose health
information to inform you about alternative treatments, providers, or settings and health-related
services that may be of interest to you.
RESEARCH. Your health information may be used or disclosed for research purposes where the
research has been approved by a special Privacy Board which will ensure that the researcher follows
certain privacy protections.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY. When necessary to prevent a serious
threat to your health and safety or the health and safety of the public. Any disclosure, however,
would only be to someone able to help prevent or lessen the threat.
PUBLIC HEALTH ACTIVITIES. We may disclose your health information to public health or legal
authorities to report births and deaths; to prevent or control disease, injury or disability. We may
also make disclosures to notify a person who may have been exposed to or may be at risk of
contracting or spreading a communicable disease; and to the FDA about the quality or safety of a
regulated product. We will notify a government authority if we believe that a patient has been a
victim of abuse, neglect or domestic violence, if required or authorized by law.
HEALTH OVERSIGHT ACTIVITIES. We may disclose health information to a health oversight
agency for activities authorized by law. These include, for example, audits, investigations,
inspections, and licensure, which are necessary for the government to monitor the health care
system, and compliance with civil rights laws.
JUDICIAL, ADMINISTRATIVE PROCEEDINGS AND LAWSUITS. We may disclose your health
information in response to a court or administrative order or in response to a subpoena, discovery
request, or other lawful process.
LAW ENFORCEMENT. We may disclose your health information for certain law enforcement
purposes, including, for example, to file reports or injuries required by law; report emergencies or
suspicious deaths; comply with court orders, or other legal process; identify or locate a missing
person; and to answer certain requests for information concerning crimes.
AS REQUIRED BY LAW. We may disclose your health information when required by law to do so
including laws relating to Military Activity, National Security, Workers’ Compensation and
CORONERS, MEDICAL EXAMINERS, FUNERAL DIRECTORS. We may release health information to
a coroner, medical examiner as necessary, to identify a deceased person or determine the cause of
death; and to funeral directors as necessary to carry out their duties.
BUSINESS ASSOCIATES. Some billing or office operations are provided by outside entities”
business associates”. We may disclose health information to our business associates so they can
perform their work. Our business associates are required by contract to safeguard your information.
Authorization Is Required For All Other Uses Or Disclosures Of Your Health Information
We will obtain your written permission ( “Authorization”) before making any use or disclosure
other than those described in this Notice
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. The Authorization will describe the health information to
be used or disclosed, and the reason for the disclosure. You may revoke the Authorization in writing
at any time. If you revoke your Authorization. we will no longer use or di sclose your health
infornlation for the reasons covered in the Authorization. We cannot take back disclosures we
Your Rights Regarding Health Information About You
You have the following rights regarding health information:( which may be exercised by parents,
custodial parents, or the legally authorized representative)
RIGHT TO INSPECT AND COPY: You have the right to look at, and upon written request, copy
health infonnation that may be used to make decisions about your care such as health and billing
records. We may charge a fee for copying, mailing or other items associated with your request. We
may deny your request in certain limited circumstances. If it is denied, you may ask that the denial
be reviewed by another health care professional chosen by us to review your request and the denial.
RIGHT TO REQUEST AMENDMENT. If you feel that health information we have about you is
incorrect or incomplete, you may ask us to amend the information for as long as we keep the
information. Your request must be made in writing on a form provided by us and must provide a
reason for your request. We may deny your request if the information was not created by us, unless
the person/entity that created the information is no longer available to make the amendment; or is
not part of the health information kept by or for our practice: or is not part of the information you
would be permitted to look at or copy; or the information is accurate and complete. If we deny your
request, we will give you a written explanation. You may submit a written statement of
disagreement which will be kept on file with your record.
RIGHT TO AN ACCOUNTING OF DISCLOSURES. You have the right to request an accounting of
certain non-routine disclosures of your health information, which we have made, except for
disclosures for treatment, payment, and health care operations, or disclosures made to you or the
patient’s authorized representative.
You must submit your request in writing and state a time period beginning after 12/01/11 and which
may not be longer than six years. The first request within a l2-month period will be free; we may
charge a reasonable fee for additional requests. Requests will be answered within 60 days of the
request unless we notify you within that time of an extension, which may not exceed 30 days.
RIGHT TO REQUEST RESTRICTIONS. You have the right to request in writing that we restrict or
limit the way we use or disclose your personal health information for treatment, payment or health
care operations and/or to restrict the health information we may disclose to a particular family
member, or other person who is involved with your care or payment for your care. We are not
required to agree to these restrictions. If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment or the disclosure is required by law.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS. You have the right to request in writing
that we communicate with you about health matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or send test results to a specific address. We
will not ask you the reason for your request and will accommodate reasonable requests.
Changes To This Notice
We reserve the right to change this notice and to make the revised notice effective for health
information we already have about you as well as any information we create or receive in the future.
If we make material changes, we will post a copy of the revised notice in our office and make it
available to you upon request. The effective date of this notice is Dec 1,2011.
If you believe your privacy rights have been violated, you may file a complaint directly or in
writing by contacting the Privacy Officer at Ramapo Valley Pediatrics or with the Office of Civil
Rights in the U.S.Department of Health and Human Services at 200 Independence Avenue, S.W.,
Room 509 F, HHH Building, Washington D.C. 20201 .
To file a complaint in person or to request a complaint fonn, please contact: Privacy Officer at 845-
368-0422. You will not be penalized or retaliated against for filing a complaint.
For Further Information
If you have any questions about this Notice or if you would like to exercise any of the rights in this
Notice please contact, Privacy Officer at 845- 368-0422