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.
This Notice of Privacy Practices (“Notice”) applies to all Protected Health Information about you (the patient) held or transmitted by Imagine Pediatrics (“we”, “our”, “us”). Protected Health Information is any individually identifiable health information about your past, present, or future physical or mental health condition or payment for healthcare or about the provision of care to you. Protected Health Information may include information about your condition or treatment, diagnostic tests and images, and related health information.
Your privacy is important to us. We are required by law to maintain the privacy of Protected Health Information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect.
The following categories describe the different ways that we may use and disclose your Protected Health Information without your written authorization. Not every use or disclosure within a category will be listed. Your Protected Health Information may be stored in paper, electronic or other form and may be disclosed electronically and by other methods.
Treatment. We may use and disclose your Protected Health Information for your treatment. For example, we may disclose your Protected Health Information to a specialist to whom we refer you.
Payment. We may use and disclose your Protected Health Information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections and claims management. These activities also include determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your health insurance provider containing certain Protected Health Information.
Healthcare Operations. We may use and disclose your Protected Health Information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, arranging for legal services, conducting training programs, reviewing the competence and qualifications of healthcare professionals, and licensing activities. We may also use your Protected Health Information to notify you about our health-related products and services, to recommend possible treatment options or alternatives that may interest you, to send you patient satisfaction surveys, or to send you appointment reminders. We may make incidental disclosures of limited Protected Health Information, such as by mailing statements to you with your name on the envelope.
Business Associates. We may disclose your Protected Health Information to one or more of our service providers, known as “business associates,” in order for them to provide services to us or on our behalf. Our business associates are required by written agreement to safeguard your Protected Health Information and otherwise protect your privacy as required by law.
Health Information Exchanges. We may participate in one or more Health Information Exchanges (HIEs) and may electronically share your Protected Heath Information for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your health care providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes. To opt out of participating in our HIEs, complete the Health Information Exchange (HIE) Opt-Out Request Form – Click HERE for English and HERE for Spanish.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your Protected Health Information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, if a person has the authority by law to make healthcare decisions for you, we may disclose information about you to such patient representative and treat that patient representative the same way we would treat you with respect to your Protected Health Information. We may also disclose your Protected Health Information to a public or private entity authorized by law to assist in disaster relief efforts to notify, or assist in notifying, a family member or personal representative about your location, general condition, or death.
Required by Law. We may use or disclose your Protected Health Information when we are required to do so by law. For example, we may disclose Protected Health Information about you to the U.S. Department of Health and Human Services if it requests such information to determine that we are complying with federal privacy law.
Public Health Activities. We may disclose your Protected Health Information to public health authorities that are authorized by law for public health activities, such as to prevent or control disease, injury or disability. We may also disclose your Protected Health Information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if we or a public health authority is authorized by law to notify such person as necessary in the conduct of a public health intervention or investigation.
Proof of Immunization to Schools. We may disclose your PHI to a school at which you are a student or prospective student, but only to disclose proof of immunization where the school is required by state or other law to have proof of immunization. We will only disclose your proof of immunization if we are able to obtain and document an agreement to the disclosure from a parent, guardian, or other person acting in loco parentis, or, if you are an emancipated minor, from you.
Abuse, Neglect or Domestic Violence. If we reasonably believe that you are a victim of abuse, neglect, or domestic violence, we may disclose your Protected Health Information to a government authority, including a social service protective agency, authorized by law to receive reports of abuse, neglect or domestic violence.
Health Oversight Activities. We may disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure actions.
Law Enforcement. We may disclose your Protected Health Information for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Judicial and Administrative Proceedings. We may disclose your Protected Health Information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.
Serious Threat to Health or Safety. We may disclose your Protected Health Information when permitted by law to avert a serious and imminent threat to the health or safety of a person or the public.
Specialized Government Functions. To the extent applicable, we may release your Protected Health Information for specialized government functions, including military and veterans activities, national security and intelligence activities, and correctional institutions.
Worker’s Compensation. To the extent applicable, we may disclose your Protected Health Information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Coroners, Medical Examiners, and Funeral Directors. We may release your Protected Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose your Protected Health Information to funeral directors consistent with applicable law to enable them to carry out their duties.
Research. We may use or disclose your Protected Health Information for research in limited circumstances, including when an institutional review board or privacy board has reviewed the research proposal and established a process to ensure the privacy of the requested information and approves the research.
Organ Donation. We may use and disclose information to entities involved in procuring, banking, and transplanting organs, eyes and tissues to assist with donation or transplantation.
Limited Data and De-identified Data. We may remove most information that identifies you from a set of data and use and disclose this data set for research, public health and healthcare operations, provided the recipients of the data set agree to keep it confidential. We may also de-identify your Protected Health Information and use and disclose the de-identified information for purposes permitted by law.
In any other situation not identified in this Notice, we will ask for your authorization before using or disclosing information about you. Most uses and disclosures of Protected Health Information for marketing purposes and disclosures that constitute a sale of health information will be made only with your written authorization. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your Protected Health Information for the purpose previously authorized, except to the extent that we have already taken action in reliance on the authorization.
Right to Access. You have the right to inspect and obtain copies of your Protected Health Information that we maintain and to direct us to send your Protected Health Information stored in an electronic health record to another person designated by you, with limited exceptions, as provided by 45 CFR § 164.524. This right applies to PHI used to make decisions about you or payment for your care, subject to limited exceptions. You must make the request in writing at the address listed at the end of this Notice. In most cases, we will provide access to you or the person you designate to get access within 30 days of your request or, if applicable, any shorter time period required by law. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. If you are denied a request for access, in certain circumstances you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Right to Request Amendment. You have a right to request that we amend your Protected Health Information if you believe the information is not accurate or is incomplete, as provided by 45 CFR § 164.526. To request an amendment of your health information, you must submit your request in writing to the address listed at the end of this Notice. Your request must explain why the information should be amended. We may deny your request under certain circumstances.
Right to an Accounting of Disclosures. You have a right to receive an accounting of certain disclosures of your Protected Health Information, as provided by 45 CFR § 164.528. To request an accounting of disclosures of your health information, you must submit your request in writing to the address listed at the end of this Notice. If you request more than one accounting of disclosures within any 12 month period, we reserve the right to charge you a reasonable, cost-based fee for each subsequent request.
Right to Request a Restriction. You have the right to request additional restrictions on certain uses and disclosures of your Protected Health Information for treatment, payment or healthcare operations, as provided by 45 CFR § 164.522(a). You must make your request in writing. We are not required to agree to your request, except we are required to agree if your request is to restrict disclosures to a health plan for purposes of carrying out payment or healthcare operations, and the information pertains solely to a healthcare item or service for which you, or a person on your behalf (other than the health plan), has paid us out-of-pocket in full.
Right to Alternative Communication. You have the right to request that we communicate with you about your Protected Health Information by alternative means or at alternative locations, as provided by 45 CFR § 164.522(b). You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.
Right to a Paper Copy of this Notice. You have a right to obtain a paper copy of this Notice upon request.
If you have given another individual a medical power of attorney, if another individual is appointed as your legal guardian or if another individual is authorized by law to make healthcare decisions for you (such as your custodial parent) (known as a “personal representative”), that individual may exercise any of the above rights listed for you.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all Protected Health Information that we maintain. When we make a material change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently any practice location we operate and on our website, and we will provide copies of the new Notice upon request.
If you want more information about our privacy practices, please contact us as the address below. If you believe your privacy rights may have been violated, please contact the Privacy Officer below. You also have the right to file a complaint with the Privacy Officer listed below or with the Office for Civil Rights, U.S. Department of Health and Human Services. We will not retaliate against you in any way for filing a complaint.
Privacy Officer: Mariana Pope
Telephone: (833) 208-7770
E-mail: mpope@imaginepediatrics.org
