Premier 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.

USE AND DISCLOSURE OF HEALTH INFORMATION

Premier Pediatrics, LLC may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Premier Pediatrics has established policies to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment. Premier Pediatrics may use your health information to coordinate care within the Premier Pediatrics and with others involved in your care, such as your attending physician, and other health care professionals who have agreed to assist Premier Pediatrics in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.

Premier Pediatrics also may disclose your health information to individuals involved in your care including family members, pharmacists, suppliers of medical equipment or other health care professionals.

To Obtain Payment. Premier Pediatrics may include your health information in invoices to collect payment from third parties for the care you receive from Premier Pediatrics. For example, Premier Pediatrics may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Premier Pediatrics. Premier Pediatrics also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for care and the services that will be provided to you.

To Conduct Health Care Operations. Premier Pediatrics may use and disclose health information for its own operations in order to facilitate the function of your care and as necessary to provide quality care to all of the Premier Pediatrics’ patients. Health care operations include such activities as:

  • Professional review and performance evaluation.
  • Activities designed to improve health or reduce health care costs.
  • Training programs including those in which students, trainees or practitioners in health care learn under supervision.
  • Training of non-health care professionals.
  • Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
  • Business planning and development including cost management and planning related analyses and formulary development.
  • Business management and general administrative activities.
  • Fundraising for the benefit of Premier Pediatrics.

For Marketing Activities. Premier Pediatrics will occasionally ask patients and families to share their stories or comments in regards to services received. Before this may happen you or your representative will be asked to provide consent for the specific use.

For Appointment Reminders. Premier Pediatrics may use and disclose your health information to contact you as a reminder that you have an appointment for a visit.

For Treatment Alternatives. Premier Pediatrics may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED:

When Legally Required. Premier Pediatrics will disclose your health information when it is required to do so by any Federal, State or local law.

When There Are Risks to Public Health. Premier Pediatrics may disclose your health information for public activities and purposes in order to:

  • Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.
  • Report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
  • Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
  • Notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence. Premier Pediatrics is allowed to notify government authorities if Premier Pediatrics believes a patient is the victim of abuse, neglect or domestic violence. Premier Pediatrics will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities. Premier Pediatrics may disclose your health information to a health oversight at Premier Pediatrics for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. Premier Pediatrics, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings. Premier Pediatrics may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process. Premier Pediatrics will make reasonable efforts to obtain assurance from the entity delivering the order, that steps have been taken to notify you.

For Law Enforcement Purposes. As permitted or required by State law, Premier Pediatrics may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • To a law enforcement official if the Premier Pediatrics has a suspicion that your death was the result of criminal conduct including criminal conduct of the Premier Pediatrics.
  • In an emergency in order to report a crime.

To Medical Examiners. Premier Pediatrics may disclose your health information to medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

For Organ, Eye Or Tissue Donation. Premier Pediatrics may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes. Premier Pediatrics may, under very select circumstances, use your health information for research. Before Premier Pediatrics discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Your written authorization is required for all other research purposes.

In the Event of A Serious Threat To Health Or Safety

Premier Pediatrics may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Premier Pediatrics, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions. In certain circumstances, the Federal regulations authorizes Premier Pediatrics to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation. Premier Pediatrics may release your health information for worker’s compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Uses and disclosures of your protected health information that involve marketing, sale of your protected health information, certain research purposes, or any other uses and disclosures not described in this notice or required by law will be made only with your written authorization. If you or your representative authorizes the Premier Pediatrics to use or disclose your health information, you may revoke that authorization in writing at any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that the Premier Pediatrics maintains:

  • Right to request restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Premier Pediatrics’ disclosure of your health information to someone who is involved in your care or the payment of your care. Premier Pediatrics must comply with your request if the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for the purpose of carrying out treatment) and the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full by you. Otherwise, Premier Pediatrics is not required to agree to your request. If you wish to make a request for restrictions, please contact the Privacy Official in writing at 7960 SW 60th Ave Ocala, FL 34476
  • Right to receive confidential communications. You have the right to request that the Premier Pediatrics communicate with you in a certain way. For example, you may ask that the Premier Pediatrics only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact the Privacy Official in writing at 7960 SW 60th Ave Ocala, FL 34476. The Premier Pediatrics will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
  • Right to inspect and copy your health information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made in writing to the Privacy Official at 7960 SW 60th Ave Ocala, FL 34476. If you request a copy of your health information, Premier Pediatrics may charge a reasonable fee for copying and assembling costs associated with your request. You have the right to request a copy of your health information that is maintained electronically in an electronic format if it is readily producible. You also have the right to request Premier Pediatrics to transmit a copy of this information directly to a designated third party on your behalf. We may charge a reasonable fee for producing the electronic copy of your health information.
  • Right to amend health care information. You or your representative have the right to request that Premier Pediatrics amend your records, if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by the Premier Pediatrics. A request for an amendment of records must be made in writing to the Privacy Official, 7960 SW 60th Ave Ocala, FL 34476. Premier Pediatrics may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Premier Pediatrics, if the records you are requesting are not part of the Premier Pediatrics’ records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Premier Pediatrics, the records containing your health information are accurate and complete.
  • Right to a paper copy of this notice. You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously. To obtain a separate paper copy, please contact the Privacy Official in writing at 7960 SW 60th Ave Ocala, FL 34476.
  • Right to breach notification. You have a right to be notified if a breach of your unsecured protected health information has occurred. Unauthorized disclosure of your health information is presumed to be a breach unless a risk assessment shows a low probability that the information was compromised.

DUTIES OF Premier Pediatrics, LLC.

Premier Pediatrics is required by law to maintain the privacy of your health information and to provide you and your representative this Notice of its duties and privacy practices. Premier Pediatrics is required to abide by the terms of this Notice as may be amended from time to time. Premier Pediatrics reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Premier Pediatrics changes its Notice, the Premier Pediatrics will provide a copy of the revised Notice to you or your appointed representative. You or your personal representative have the right to express complaints to the Premier Pediatrics and to the Secretary of the U.S. Department of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to the Premier Pediatrics should be made in writing to the Privacy Official at 7960 SW 60th Ave Ocala, FL 34476. The Premier Pediatrics encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

Premier Pediatrics has designated the Privacy Official as its contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 7960 SW 60th Ave Ocala, FL 34476 (352) 671-6741.

DISCLAIMER

When the patient is 18 yrs or older the word “you” refers to the patient. When patient is a minor and a parent or guardian is signing this document the word “you” still refers to the patient ,not the person who is signing the document.

EFFECTIVE DATE

This Notice is effective November 2013.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT

Privacy Official at 7960 SW 60th Ave Ocala, FL (352) 671-6741

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