Office Info: Notice of Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR CHILD (AS A PATIENT OF THIS PRACTICE ) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR CHILD'S INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR CHILD'S PRIVACY
Our practice is dedicated to maintaining the privacy of your child's individually identifiable health information (IIHI). In conducting our business, we will create records regarding your child and the treatment and services we provide to your child. We are required by law to maintain the confidentiality of health information that identifies your child. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child's IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your child's IIHI
• Your child's privacy rights in your child's IIHI
• Our obligations concerning the use and disclosure of your child's IIHI

The terms of this notice apply to all records containing your child's IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your child's records that our practice has created or maintained in the past, and for any of your child's records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477

C. WE MAY USE AND DISCLOSE YOUR CHILD'S INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS. The following categories describe the different ways in which we may use and disclose your child's IIHI.

1. Treatment. Our practice may use your child's IIHI to treat your child. For example, we may ask your child 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 your child's IIHI in order to write a prescription for him/her, or we might disclose your child's IIHI to a pharmacy when we order a prescription for him/her. Many of the people who work for our practice - including, but not limited to, our doctors and nurses - may use or disclose your child's IIHI in order to treat him/her or to assist others in your child's treatment. Additionally, we may disclose your child's IIHI to others who may assist in your child's care, such as relatives, babysitters, or anyone who brings your child to our office for care. Finally, we may also disclose your child's IIHI to other health care providers for purposes related to your child's treatment.

2. Payment. Our practice may use and disclose your child's IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your child's health insurer to certify that he/she is eligible for benefits (and for what range of benefits), and we may provide your child's insurer with details regarding your child's treatment to determine if your child's insurer will cover, or pay for, your child's treatment. We also may use and disclose your child's IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your child's IIHI to bill you directly for services and items. We may disclose your child's IIHI 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 your child's IIHI to operate our business. As examples of the ways in which we may use and disclose your child's information for our operations, our practice may use your child's IIHI 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 IIHI to other health care providers and entities to assist in their health care operations.

4. Appointment Reminders. Our practice may use and disclose your child's IIHI to contact you and remind you of an appointment.

5. Treatment Options. Our practice may use and disclose your child's IIHI to inform you of potential treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your child's IIHI to inform you of health-related benefits or services that may be of interest to you.

7. Release of Information to Family/Friends. Our practice may release your child's IIHI to a friend or family member that is involved in your child's care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician's office for treatment of a cold. In this example, the babysitter may have access to this child's medical information.

8. Disclosures Required By Law. Our practice will use and disclose your child's IIHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR CHILD'S IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your child's identifiable health information:

1. Public Health Risks. Our practice may disclose your child's IIHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths
• Reporting child abuse or neglect
• Preventing or controlling disease, injury or disability
• Notifying a person regarding potential exposure to a communicable disease
• Notifying a person or entity regarding a potential risk for spreading or contracting a disease or condition
• Reporting reactions to drugs or problems with products or devices
• Notifying individuals if a product or device they may be using has been recalled
• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult (including domestic violence); however, we will only disclose this information if the individual agrees or we are required or authorized by law to disclose this information
• Notifying your employer under limited circumstances related primarily to a caretaker's need to miss work due to a child's illness

2. Health Oversight Activities. Our practice may disclose your child's IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure an disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your child's IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your child's IIHI in response to a discovery request, subpoena, or other lawful process by another party.

4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to
• btain the person's agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

Effective Date of this Notice: April 14, 2003
• Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to
• Organ and Tissue Donation. Our practice may release your child's IIHI to organizations that handle organ, eye or tissue
• Research. Our practice may use and disclose your child's IIHI for research purposes in certain limited circumstances. We:

5. identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and
transplantation if you are an organ donor.

7. will obtain written authorization to use your child's IIHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your child's authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your child's privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which to use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

• Serious Threats to Health or Safety. Our practice may use and disclose your child's IIHI when necessary to reduce or
• Military. Our practice may disclose your child's IIHI if the parent is a member of U.S. or foreign military forces
• National Security. Our practice may disclose your child's IIHI to federal officials for intelligence and national security

YOUR RIGHTS REGARDING YOUR CHILD'S IIHI
You have the following rights regarding the IIHI that we maintain about your child:
• Confidential Communications. You have the right to request that our practice communicate with you about your child's
• Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your child's IIHI for
f your

8. prevent a serious threat to your child's health and safety or the health and safety of another individual or the public. Under
these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. (including veterans) and if required by the appropriate authorities.

10. activities authorized by law. We also may disclose your child's IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

1. 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 Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of child's IIHI to only certain individuals involved in your child's care or the payment for your child's 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 you. In order to request a restriction in our use or disclosure of your child's IIHI, you must make your child's request in writing to Privacy
Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477. 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.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions.

Amendment. You may ask us to amend your child's health information if you believe it is incorrect or incomplete about your and/or your child, including patient medical records and billing records, but not including psychotherapy notes. You must submit your child's request in writing to Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 Howell Road, Maitland, FL 32751 (407) 767-2477 in order to inspect and/or obtain a copy of your child's IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice 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 reviews.

4. 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 Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A.

Effective Date of this Notice: April 14, 2003
5. Accouting of Disclosures. All of our patients have the right to request an "accounting of disclosures." New Interlachen Pediatrics, P.A., 846 Howell Road, Maitland, FL 32751 (407) 767-2477. 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 the request if you ask us to amend information that is in our opinion: (a) accurat complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI 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. undisclosures" is a list of certain non-routine disclosures our practice has made of your child's IIHI for non-treatment, non-payment or non-operations purposes. Use of your child's IIHI as part of the routine patient care in our practice is not request to be documented. For example, the doctor sharing information with the nurse; or the billing department using your child's information to file your child's insurance claim. In order to obtain an accounting of disclosures, you must submit your child' request in writing to Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477. All requests for an "accounting of disclosures" must state a time period, which may be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you 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 child request before you incur any costs.

• Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You
• Right to File a Complaint. If you believe your child's privacy rights have been violated, you may file a complaint with
• Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization

6. May ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477.

7. Our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Privacy Officer, c/o Medical Records, New Interlachen Pediatrics, P.A., 846 lake Howell Road, Maitland, FL 32751 (407) 767-2477. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. 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 IIHI may be revoked at any time in writing. After you revoke your child's authorization, we will no longer use or disclose your child's IIHI for the reasons described in the authorization. Please note, we are required to retain records of your child's care.