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HIPAA NOTICE of Privacy Practices

A. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff
and others outside of our office that are involved in your care and treatment for the purpose of
providing health care services to you, to pay your health office care bills, to support the operation
of the physician’s and any other use required by law.
1. Treatment: Our practice may use IHI for treatment purposes. For example, we may ask our
patients 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 IHI in order to write a prescription for your child, or we
might disclose IHI to a pharmacy when we order a prescription for your child. Many of the
people who work for our practice – including, but not limited to, our doctors and nurses – may
use or disclose IHI in order to treat or to assist others in your child’s treatment. Additionally, we
may disclose IHI to others who may assist in your child’s care, such as your parents/guardians,
other relatives, caretakers.
Finally, we may also disclose IHI to other health care providers for purposes related to
2. Payment: Our practice may use and disclose IHI in order to bill and collect payment for the
services and items received from us. For example, we may contact a health insurer to certify
eligibility for benefits (and for what range of benefits), and we may provide the insurer with
details regarding treatment to determine if the insurer will cover, or pay for, your child’s
treatment. We also may use and disclose IHI to obtain payment from third parties that may be
responsible for such costs, such as family members. Also, we may use IHI to bill you directly for
services and items. We may disclose IHI 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 IHI 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 IHI 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 child’s
IHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders and Test result calls: Our practice may use and disclose IHI to
remind our patients of an appointment and test results, either by phone, mail, or e-mail. (This
includes leaving messages on voice mails and answering machines.)
5. Treatment Options, Health-Related Benefits/Services: Our practice may use and disclose
IHI to inform our families of potential treatment options or alternatives as well as health-related
benefits/services that may of interest to them.
6. Release of Information to Family/Friends: Our practice may release IHI to a friend or
family member that is involved in a patient’s care. For example, a parent or guardian may ask
that a babysitter or neighbor take their child to the office for treatment of a cold. In this example,
the babysitter or neighbor may have access to your child’s medical information.
7. Disclosures Required By Law: Our practice will use and disclose IHI when we are required
to do so by federal, state or local law.
You May revoke this authorization, at anytime, in writing, except to the extent that your
physician or physician’s practice has taken an action in reliance on the use or disclosure
indicated in the authorization.
The following categories describe unique scenarios in which we may use or disclose your
identifiable health information:
1. Public Health Risks
2. Health Oversight Activities
3. Lawsuits and Similar Proceedings
4. Law Enforcement
5. Deceased Patients
6. Organ and Tissue Donation
7. Research
8. Serious Threats to Health or Safety
9. Military
10. National Security
11. Inmates
12. Workers’ Compensation
You have the following rights regarding the IHI that we maintain about your child:
1. Confidential Communications. You have the right to request that our practice communicate
with you about 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 Melissa Castro, Office
Manager, 410-224-3663 specifying the requested method of contact, or the location where you
wish to be contacted. Our practice will accommodate reasonable requests with consideration to
your child’s confidentiality. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of
your child’s IHI for treatment, payment or health care operations. Additionally, you have the
right to request that we restrict our disclosure of your child’s IHI 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 your child. In order to request a restriction in our use or disclosure of IHI, you
must make your request in writing to Melissa Castro(see above). Your request must describe in a
clear and concise fashion:
(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) to whom you want the limits to apply; and
(d) what period of time the restrictions are to apply
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IHI that may be
used to make decisions about your child consistent with confidentiality guidelines, including
patient medical records and billing records, but not including specialists referral notes. You must
submit your request in writing to Melissa Castro, Office Manager, 410-224-3663 in order to
inspect and/or obtain a copy of your child’s IHI. Our practice may charge a fee consistent with
state guidelines 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 conduct such a review.
4. Amendment. You may ask us to amend your child’s health information if you believe it is
incorrect or incomplete, and you may request an amendment for as long as the information is
kept by or for our practice. To request an amendment, your request must be made in writing and
submitted to Melissa Castro, Office Manager, 121 Old Solomons Island Rd, Annapolis, MD 21401. You
must 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 IHI originated and kept by or for the
practice; (c) not part of the IHI 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 information.
5. 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 child’s IHI for non-treatment, non-payment or non-operations
purposes. Use of your child’s IHI as part of the routine patient care in our practice is not required
to be documented or accounted for. For example, a doctor sharing information with the nurse; or
the billing department using your child’s information to file your insurance claim. In order to
obtain an accounting of disclosures, you must submit your request in writing to Melissa Castro,
Office Manager, 410-224-3663. All requests for an “accounting of disclosures” must state a
time period. Our practice may charge you consistent with state guidelines 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.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice
of privacy practices. You may ask us to give you a copy of this notice at any time.
7. Right to File a Complaint. If you believe your child’s 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 Melissa Castro, Office
Manager, 410-956-6302. All complaints must be submitted in writing. You will not be
penalized for filing a complaint.
8. 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 child’s IHI may be revoked at any time in writing. After you revoke your
authorization, we will no longer use or disclose your child’s IHI for the reasons described in the
authorization. Please note, we are required to retain records of your care.
Again, if you have any questions regarding this notice or our health information privacy policies,
please contact Melissa Castro at Chesapeake Pediatrics, 121 Old Solomons Island Rd, Annapolis, MD 21401.

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