Notice of How VIP PEDIATRICS Protects the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

VIP PEDIATRICS may use or disclose your proctected health information (PHI) for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in any health care records VIP PEDIATRICS maintains regarding you that could identify you.
• "Treatment, Payment and Health Care Operations"
  • Treatment is when VIP PEDIATRICS provides, coordinate or manage your health care and other services related to your health care. An example of treatment would be when VIP PEDIATRICS consults with another health care provider.
  • Payment is when VIP PEDIATRICS obtains reimbursement for your healthcare. Examples of payment are when VIP PEDIATRICS discloses your PHI to any third party payer to obtain reimbursement for your health care or to determine eligibility or coverage.
  • Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• "Use" applies only to activities within my practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• "Disclosure" applies to activities outside my practice such as releasing, transferring, or providing access to information about you to other parties.

VIP PEDIATRICS may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission permitting specific disclosures above and beyond those permitted by the general consent. In those instances when VIP PEDIATRICS is asked for information for purposes outside of treatment, payment and health care operations, VIP PEDIATRIC will obtain an authorization from you before releasing this information. VIP PEDIATRIC will also need to obtain an authorization before releasing your medical records. You may revoke all such authorizations (regarding PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) VIP PEDIATRICS has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

VIP Pediatrics may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If VIP PEDIATRICS has cause to believe that a child has been, or may be, abused, neglected, or sexually abused, VIP PEDIATRICS must make a report of this belief within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or any local or state law enforcement agency.
• Adult and Domestic Abuse: If VIP PEDIATRICS has cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, VIP PEDIATRICS must immediately report this belief to the Department of Protective and Regulatory Services.
• Health Oversight: If a complaint is filed against me with the Texas State Board of Medical Examiners they have the authority to subpoena confidential medical information from me relevant to that complaint.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law. VIP PEDIATRICS will not release such information unless VIP PEDIATRICS has either written authorization from you or your personal or legally appointed representative or else a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Serious Threat to Health or Safety: If VIP PEDIATRICS determines that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, VIP PEDIATRICS may disclose relevant confidential medical information to medical or law enforcement personnel.
• Worker’s Compensation: If you file a worker’s compensation claim, VIP PEDIATRICS may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.

Your Rights:

• Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, VIP PEDIATRICS is not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations. You have the right to request and receive confidential communications of Pill by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, VIP PEDIATRICS will send any mail to you at another address that you provide me.)
• Right to Inspect and Copy. You have the right to inspect or obtain a copy (or both inspect and obtain a copy) of PHI and billing records used to make decisions about you for as long as the PHI is maintained in the record. VIP PEDIATRICS may charge a reasonable fee for copying expenses.
• Right to Amend. You have the right to request an amendment of Pill for as long as the PHI is maintained in the record. VIP PEDIATRICS is not required to accept your request for amendment.
• Right to Request Restriction or Accounting. You may request restrictions on how VIP PEDIATRICS uses and/or discloses your PHI. You generally have the right to receive an accounting of disclosures of PHI for which you have provided neither consent nor authorization (as described in Section III of this Notice).
• Right to Request Confidential Communications. You may request communications from VIP PEDIATRICS concerning your PHI be made in certain ways or at a certain location. You must specify any preferences regarding confidential communications in writing.
• Right to a Paper Copy. You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

My Duties:

• VIP PEDIATRICS is required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• VIP PEDIATRICS reserves the right to change the privacy policies and practices described in this notice. Unless VIP PEDIATRICS notifies you of such changes, however, VIP PEDIATRICS is required to abide by the terms currently in effect.
• VIP PEDIATRICS may revise the terms of this notice. If VIP PEDIATRICS revises this notice, VIP PEDIATRICS will follow the terms of the revised notice from date of revision.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision VIP PEDIATRICS makes about access to your records, or have other concerns about your privacy rights, you may contact me.
If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me at the address provided on my letterhead.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. VIP PEDIATRICS can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. VIP PEDIATRICS will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on March 6, 2006. VIP PEDIATRICS reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that VIP PEDIATRICS maintains. A copy of the current notice will be posted at our office for your review at each office visit. Additionally, a copy will be available at www.vippediatrics.com with the effective date at the top of the notice.