River's Edge Pediatrics, Inc. Privacy Statement

Practice Privacy Statement 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. I. This is formal notification, as required by CMS (Centers for Medicare and Medicaid Services) concerning the privacy policy of this practice. It is important that all patients and staff understand the importance of maintaining the privacy of patient information. II. This practice has a legal obligation to maintain all medical records and information in the strictest of confidence as required by law. We cannot release information to others without your written consent, including conversations, reminder calls, test results and other information that may be of a confidential nature. Patient information about health care information is identified as ?PHI? or protected health information. This change in policy requires that you, the parent/legal guardian, identify and clarify at the time of registration or re-registration with this practice to whom we can talk, how we can leave information on your behalf, and the process for ongoing continuity of your child?s medical care. You can change this information at any time with either written notification or verbal notification, which is then provided in writing. Changes can only impact the care or information from that point in time forward. III. Your protected health information (PHI) is an intricate part of your child?s medical care, and can be used or disclosed with your written consent: · For your child?s treatment in this practice and other locations under the physician?s immediate care. This may include any referral for services such as lab, x-rays, other diagnostic testing or treatment related to your child?s condition or medical care needs. This may also include conversations with other physicians. · For obtaining payment for treatment with your identified insurance or health coverage program. This would include any documentation related to this process, which may include history forms, progress notes or operative notes. This would include eligibility verification, prior authorization and claim submission. · For operations of this practice, such as enrolling with insurance programs, hospital privileges, accounting and compliance with federal and state laws and regulations. · For appointment reminders and health related benefit services only with your consent as identified on the registration form. · For disclosure to your family and friends concerning any related health care information on the registration form which can be modified at any time orally, followed by written consent. · Consent is not required for emergency care and treatment. An emergency is identified as a medical condition that in the judgment of the physician or medical entity required immediate and full information for care on your behalf. Certain disclosures can be made without your consent: · Disclosure required by the government or law enforcement agencies. Specific areas that require release include gun shot wounds, domestic violence and victims of abuse or neglect. · Information used for public health purposes (ex. Reporting of extremely communicable diseases; communication regarding a child?s death). · Information used for health care credentialing, such as a site and chart review by an insurance program. · Information related to organ donation. · Information related to certain research procedures. The majority of this information is void of any personal data, and is normally generic (age, sex, diagnosis) in nature. · Information provided to avoid harm if there is a threat to patient or other safety. · Specific governmental functions. · Worker?s compensation review. IV. Your rights with respect to your child?s protected health information. · The right to request limits on the uses and disclosures at registration or any time during you care. · The right to choose how we provide this information to you, including an alternate address. · The right to see and obtain copies of this information; there may be copy and postage fees. · The right to obtain a listing of whom we have made the disclosures regarding your child?s PHI. · The right to correct and update your file through an amendment process. V. This practice reserves the right to modify or change this Privacy Statement and process at any time. Revision to the Statement will be available upon request by contacting the office. The changes will be effective retroactively to the initial date of the Privacy Statement. An updated Privacy Statement will be posted in the office within 60 days of the revision. VI. If you have a concern or complaint about how your protected health information is being used, from this date forward, you should contact our office for a possible resolution. You may contact the Office of Civil Rights or the Ohio Medicare Carrier, GBA Palmetto, if you are not satisfied with our response. · Contact the Office Manager and complete a complaint form for review and discussion: River?s Edge Pediatrics, Inc. Attn: Office Manager 100 N. High Street, Suite A Dublin, Ohio 43017 (614) 889-7772 · If you are not satisfied with this response, you may report the practice to: Office of Civil Rights Regional Manager Department of Health & Human Services 233 N. Michigan Avenue, Suite 240 Chicago, Illinois 60601 (312) 886-1807 Or the local Medicare Part B Intermediary GBA Palmetto Part B Operations ? HIPAA Compliance Concern PO BOX 182957 Columbus, Ohio 43218 This privacy plan is a working draft, which became effective December 1, 2002. Parent/Legal Guardian signature on receipt of Privacy Notice:____________________________________ Date:_________________ Parent/Legal Guardian unable to sign due to:__________________________________________________Date:_________________ Parent/Legal Guardian refused to sign ? witness:_______________________________________________Date:_________________ (Copy maintained in chart)