NOTICE OF PRIVACY PRACTICES
SOUTH DAYTON PEDIATRICS, INC.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSES AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The terms of this Notice of Privacy Practices apply to South Dayton Pediatrics and the physicians, Dr. Thomas J. Sorauf, Dr. Azar Kardan,
Dr. Sylvia Parks, Dr. Suzanne Williams, Jessica Sanchez NP, and other licensed professional seeing and treating patients. All of the entities and persons listed will share personal health information of patients as necessary to carry out treatment, receive payment, and health care operations as permitted by law.
We are required by law to maintain the privacy of our patients’ personal health information and to provide patients with notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of the Notice of Privacy Practices as necessary and to make the new Notice effective for all personal health information maintained by us. You may receive a copy of any revised notices by mailing a request to Privacy Officer, South Dayton Pediatrics, Inc., 617 Shroyer Road, Dayton, Ohio 45419.
USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION
Your Authorization. Except as outlined below, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.
Uses and Disclosures for Treatment. We will make uses and disclosures of your personal health information as necessary for your treatment. For instance, doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, tests, etc. We may also release your personal health information to another health care facility or professional who is not affiliated with our organization but who is or will be providing treatment to you.
Uses and Disclosures for Payment. We will make uses and disclosures of your personal health information as necessary for the payment purposes of those health professionals that have treated you or provided services to you. For instance, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you or we may use your information to prepare a bill to send to you or to the person responsible for your payment.
Uses and Disclosures for Health Care Operations. We will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations which include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and care of our patients. We may also disclose your personal information to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a patient relationship with you.
Family and Friends Involved In Your Care. With your approval, we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individual’s without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.
Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, legal services, etc. At times it may be necessary for us to provide certain of your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.
Appointments and Services. We may contact you to provide appointment reminders or test results. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You may request such confidential communications in writing and may send your request to Privacy Officer, South Dayton Pediatrics, Inc., 617 Shroyer Road, Dayton, Ohio, 45419.
Research. In limited circumstances we may use and disclose your personal health information for research purposes. For example, a researcher may want to compare outcomes of all patients that received a particular drug and will need to review a series of medical records. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by representations of the researchers that limit their use and disclosure of patient information.
Other Uses and Disclosure. We are permitted or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization.
We may release your personal health information for any purpose required by law;
We may release your personal health information for public health activities, such as required reporting of disease, injury, birth, death, and for required public health investigations;
We may release your personal health information as required by law if we suspect child abuse or neglect; we may also release your personal health information as required by law if we believe you to be a victim of abuse, neglect, or domestic violence;
We may release your personal health information to the Food and Drug Administration if necessary to report adverse events, product defects, or to participate in product recalls;
We may release your personal health information to your employer when we have provided health care to you at the request of your employer; in most cases you will receive notice when that information is disclosed to your employer;
We may release your personal health information if required by law to a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
We may release your personal health information to law enforcement officials as required by law to report wounds, injuries, and crimes;
We may release your personal health information to coroners and/or funeral directors consistent with the law;
We may release you personal health information if necessary to arrange an organ or tissue donation from you to a transplant for you;
We may release your personal health information for certain research purposes when such research is approved by an institutional review board with established rules to ensure privacy;
We may release your personal health information if you are a member of the military as required by armed force services; we may also release your personal health information if necessary for national security or intelligence activities; and
We may release your personal health information to workers’ compensation agencies if necessary for your workers’ compensation benefit determination.
RIGHTS THAT YOU HAVE
Access to Your Personal Health Information. You have the right to receive a copy and/or inspect much of the personal information that we retain on your behalf. All requests for access must be made in writing and signed by you or your representative. We will charge you .50/pg 1-10 pages or 1.00/pg 10 pages or more if you request a copy of the information. We will also charge for postage if you request a mailed copy and will charge for preparing a summary of the requested information if you request such summary. You may obtain an access request form from South Dayton Pediatrics, Inc.
Amendments to Your Personal Health Information. You have the right to request in writing that personal health information we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or your representative, and must state the reasons for the amendment/correction requests. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from the Privacy Officer South Dayton Pediatrics, Inc., 617 Shroyer Road, Dayton, Ohio 45419.
Accounting for Disclosures of Your Personal Health Information. You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your representative. Accounting request forms are available from the Privacy Officer, South Dayton Pediatrics, Inc. 617 Shroyer Road, Dayton, Ohio 45419. The first accounting in any 12-month period is free; you will be charged a fee of $5.00, for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your Personal Health Information. You have the right to request restriction on certain of our uses and disclosures of your personal health information for treatment, payment, or health care operations. A restriction request form can be obtained from our office manager. We are not required to agree to your restriction request but will attempt to accommodate reasonable requests when appropriate and we retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to Privacy Officer, South Dayton Pediatrics, Inc. 617 Shroyer Road, Dayton, Ohio 45419.
Complaints. If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer South Dayton Pediatrics, Inc., 617 Shroyer Road, Dayton, Ohio 45419. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
Acknowledgment of Receipt of Notice. You will be asked to sign an acknowledgment form that you received this Notice of Privacy Practices.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, South Dayton Pediatrics, Inc., 617 Shroyer Road, Dayton, Ohio 45419. As a patient you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by e-mail or other electronic means.
This Notice of Privacy Practices is effective April 14, 2003.