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)
Effective Date of this Notice: 04-13-2003
DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE)
MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION.
OUR COMMITMENT TO YOUR PRIVACY
practice is dedicated to maintaining the privacy of you/your childrens individually
identifiable health information. (Please note that
where ever we mention you in this document, it might apply to your
child if your child is our patient and not parent) In conducting our
business, we will create records regarding you and the treatment and
services we provide to you.
required by law to maintain the confidentiality of health information that
We also are
required by law to provide you with this notice of our legal duties and
the privacy practices that we maintain in our practice concerning your
and state law, we must follow the terms of the notice of privacy practices
that we have in effect at the time.
realize that these laws are complicated, but we must provide you with the
following important information:
How we may use and disclose your IIHI
Your privacy rights in your IIHI
obligations concerning the use and disclosure of your IIHI
terms of this notice apply to all records containing your 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 records that our practice has
created or maintained in the past, and for any of your 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.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT AT:
A. Patel, MD
Central Jersey Pediatrics, PC
1527 RT 27 South, Suite, 1600
Somerset, NJ 08873-3979
WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
(IIHI) IN THE FOLLOWING WAYS
following categories describe the different ways in which we may use and
disclose your IIHI.
practice may use your IIHI to treat you. For example, we may ask you 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 IIHI in order to
write a prescription for you, or we might disclose your IIHI to a pharmacy
when we order a prescription for you. Many of the people who work for our
practice � including, but not limited to, our doctors and nurses � may
use or disclose your IIHI in order to treat you or to assist others in
your treatment. Additionally, we may disclose your IIHI to others who may
assist in your care, such as your spouse, children or parents.
Finally, we may
also disclose your IIHI to other health care providers for purposes
related to your treatment.
Our practice may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us. For example,
we may contact your health insurer to certify that you are eligible for
benefits (and for what range of benefits), and we may provide your insurer
with details regarding your treatment to determine if your insurer will
cover, or pay for, your treatment. We also may use and disclose your IIHI
to obtain payment from/through third parties that may be responsible for
such costs, such as family members or collection agency. Also, we may use
your IIHI to bill you directly for services and items. We may disclose
your 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 IIHI to operate our business. As
examples of the ways in which we may use and disclose your information for
our operations, our practice may use your IIHI to evaluate the quality of
care you received from us, or to conduct cost-management and business
planning activities for our practice. We may disclose your IIHI to other
health care providers and entities to assist in their health care
practice may use and disclose your IIHI to contact you and remind you of
practice may use and disclose your IIHI to inform you of potential
treatment options or alternatives.
Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you
of health-related benefits or services that may be of interest to you.
7. Release of
Information to Family/Friends. Our practice may release your IIHI to a friend or
family member that is involved in your care, or who assists in taking
care of you. 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 up to a reasonable level.
Required By Law. Our practice will use and disclose your IIHI when we are required to do
so by federal, state or local law.
For your safety: We
do not fax any medical records.
We advice you to pick-up your
records from our office, as we do not mail or fax it. We do not call for
any prescriptions over the phone.
USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
following categories describe unique scenarios in which we may use or
disclose your identifiable health information:
Our practice may disclose your IIHI to public health authorities that
are authorized by law to collect information for the purpose of:
vital records, such as births and deaths, reporting child abuse or
or controlling disease, injury or disability.
person regarding potential exposure to a communicable disease.
person regarding a potential risk for spreading or contracting a disease
reactions to drugs or problems with products or devices.
individuals if a product or device they may be using has been recalled.
appropriate government agency (ies) and authority ( ies) regarding the
potential abuse or neglect of an adult 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
your employer under limited circumstances related primarily to workplace
injury or illness or medical surveillance.
Health Oversight Activities. Our practice may disclose your 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 IIHI in response to
a court or administrative order, if you are involved in a lawsuit or
We also may
disclose your 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.
We may release IIHI if asked to do so by law enforcement official:
crime victim in certain situations, if we are unable to obtain the
a death we believe has resulted from criminal conduct
criminal conduct at our offices
to a warrant, summons, court order, subpoena or similar legal process
identify/locate a suspect, material witness, fugitive or missing person
an emergency, to report a crime (including the location or victim(s) of
the crime, or the description, identity or location of the perpetrator
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
6. Organ and
Tissue Donation. Our practice may release your 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 you are an organ donor.
Our practice may use and disclose your IIHI for research purposes in
certain limited circumstances. We will obtain your written
authorization to use your IIHI for research purposes except when an
Internal Review Board or Privacy Board has determined that the waiver of
your authorization satisfies the following:
The use or disclosure involves no more than a minimal risk to your privacy
based on the following:
(A) An adequate plan to
protect the identifiers from improper use and disclosure;
(B) An adequate plan to
destroy the identifiers at the earliest opportunity consistent with the
research (unless there is a health or research justification for retaining
the identifiers or such retention is otherwise required by law); and
(C) Adequate written
assurances that the PHI will not be re-used or disclosed to any other
person or entity (except as required by law) for authorized oversight of
the research study, or for other research for which the use or disclosure
would otherwise be permitted;
(ii) The research could
not practicably be conducted without the waiver; and
(iii) The research could
not practicably be conducted without access to and use of the PHI.
Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary
to reduce or prevent a serious threat to your 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.
Our practice may disclose your IIHI if you are a member of U.S. or foreign
military forces (including veterans) and if required by the appropriate
practice may disclose your IIHI to federal officials for intelligence and
national security activities authorized by law. We also may disclose your
IIHI to federal officials in order to protect the President, other
officials or foreign heads of state, or to conduct investigations.
Our practice may disclose your IIHI to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law
Disclosure for these purposes would be necessary: (a) for the institution
to provide health care services to you, (b) for the safety and security of
the institution, and/or (c) to protect your health and safety or the
health and safety of other individuals.
Our practice may release your IIHI for workers� compensation and similar
RIGHTS REGARDING YOUR IIHI
the following rights regarding the IIHI that we maintain about you:
and Minor: We can use �discretion� to provide or deny
a parent access to a minor�s records as long as that decision is
consistent with state law.
Communications. You have the right to request that our practice communicate
with you about your health and related issues in a particular manner or at
a certain location. For instance, you may ask that we contact you at home,
rather than work. In order to request a type of confidential
communication, you must make a written request to us
at our official address specifying the requested method of
contact, or the location where you wish to be contacted. Our practice will
accommodate reasonable requests. You do not need to give a reason
for your request.
Restrictions. You have the right to request a restriction in our use or disclosure of
your IIHI for treatment, payment or health care operations. Additionally,
you have the right to request that we restrict our disclosure of your IIHI
to only certain individuals involved in your care or the payment for your
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 you. In order to request a
restriction in our use or disclosure of your IIHI, you must make your
request in writing to us at our official address. Your request must describe in a clear
and concise fashion:
(a) The information you
(b) Whether you are
requesting to limit our practice�s use, disclosure or both; and
(c) To whom you want the
limits to apply.
Inspection and Copies.
You have the right to inspect and obtain a copy of the IIHI that maybe
used to make decisions about you, including patient medical records and
billing records, but not including psychotherapy notes. You must submit
your request in writing to us at
our official address 30 days in advance in order to inspect
and/or obtain a copy of your IIHI. 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/or copy in
certain limited circumstances; however, you may request a review of our
denial. Another licensed health care professional chosen by us will
may ask us to amend your health information if you believe it is incorrect
or incomplete, and you may request an
amendment (Not alteration) as long as the information is kept by
our practice. To request an amendment, your request must be made in
writing and submitted to us at our
provide us with a reason that supports your request for amendment. Our
practice will deny your request if you fail to submit your request (and
the reason supporting your request) in writing. Also, 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
Accounting of Disclosures. All of our patients have the right to request an �accounting of
disclosures.� An �accounting of
disclosures� is a list of certain non-routine disclosures our practice
has made of your IIHI for non-treatment, non-payment or non-operations
purposes. Use of your IIHI as part of the routine patient care (TPO)
in our practice is not required to be documented.
example, the doctor shares information with the nurse; or the billing
department using your information to file your insurance claim. In order
to obtain an accounting of disclosures, you must submit your request in
writing to us at our official
requests for an �accounting of disclosures� must state a time period,
which may not be longer than six (6) years from the date of disclosure and
may not include dates before April 14, 2003. The first list you request
within a 12-month period is free of charge, but our practice may charge
you for additional lists within the same 12-month period. Our practice
will notify you of the costs involved with additional requests, and you
may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of
privacy practices one time. You may ask us to give you a copy of this
notice again with charge.
Right to File a Complaint. If you believe your 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, contact us
at our official address. All complaints must be submitted in
writing. You will not be penalized for filing a complaint.
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 IIHI may be revoked at any time in writing. After you
revoke your authorization, we will no longer use or disclose your IIHI for
the reasons described in the authorization. Please note that we are
required to retain records of your care.
you have any questions regarding this notice or our health information
privacy policies, please contact us
at our official address.